Patient-specific risk factors for reintervention following primary endovascular treatment of iliac artery disease

OBJECTIVE

Predictive models for reintervention may guide clinicians to optimize selection, education, and follow-up of patients undergoing endovascular iliac revascularization. Although the impact of lesion- and device-related characteristics on iliac restenosis and reintervention risk is well-defined, data on patient-specific risk factors are scarce and conflicting. This study aimed to explore the value of patient-related factors in predicting the need for clinically driven target-vessel revascularization (CD-TVR) in patients undergoing primary endovascular treatment of iliac artery disease.

METHODS

Consecutively enrolled patients undergoing endovascular revascularization for symptomatic iliac artery disease at a tertiary vascular referral center between January 2008 and June 2020 were retrospectively analyzed. Primary and secondary outcomes were CD-TVR occurrence within 24 months and time to CD-TVR, respectively. Patients who died or did not require CD-TVR within 24 months were censored at the date of death or at 730 days, respectively. Multiple imputation was used to account for missing data in primary analyses.

RESULTS

A total of 1538 iliac interventions were performed in 1113 patients (26% females; 68 years). CD-TVR occurred in 108 limbs (74 patients; 7.0%) with a median time to CD-TVR of 246 days. On multivariable analysis, increasing age was associated with lower likelihood of CD-TVR (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.50-0.83; P = .001) and decreased risk of CD-TVR at any given time (hazard ratio [HR], 0.66; 95% CI, 0.52-0.84; P = .001). Similarly, a lower likelihood of CD-TVR (OR, 0.75; 95% CI, 0.59-0.95; P = .017) and decreased risk of CD-TVR at any given time (HR, 0.73; 95% CI, 0.58-0.93; P = .009) were observed with higher glomerular filtration rates. Lastly, revascularization of common vs external iliac artery disease was associated with lower likelihood of CD-TVR (OR, 0.48; 95% CI, 0.24-0.93; P = .030) and decreased risk of CD-TVR at any given time (HR, 0.48; 95% CI, 0.25-0.92; P = .027). No associations were observed between traditional cardiovascular risk factors (sex, hypertension, higher low-density lipoprotein cholesterol, higher hemoglobin A1c, smoking) and CD-TVR.

CONCLUSIONS

In this retrospective cohort study, younger age, impaired kidney function, and external iliac artery disease were associated with CD-TVR. Traditional markers of cardiovascular risk were not seen to predict reintervention.

Revascularization with BYCROSS atherectomy device- protocol of a prospective multicenter observational study

BACKGROUND

The BYCROSS™ device is a novel device intended for use in atherectomy of the peripheral arterial disease (PAD). With the BYCROSS™ atherectomy system, also prolonged calcifying lesions can be treated in a minimally invasive manner, which was previously reserved for bypass surgery. The aim of this study is to collect additional clinical data on safety and performance of the BYCROSS™ from patients undergoing revascularization of severely stenotic or occluded peripheral arterial vessels with the BYCROSS™.

METHODS AND DESIGN

This is an investigator-initiated national prospective multicenter observational study in patients with PAD. Sixty patients (20 per center) with PAD with stenosis higher than 80% or complete occlusion (de novo or recurrent stenosis) of vessels below the aortic bifurcation (min 3 mm vessel diameter) will be recruited. Three vascular surgery centers are participating in the study. The primary efficacy endpoint is procedural success, defined as passage of the occlusion through the BYCROSS device, and safety outcomes, explicated as freedom from device-related serious adverse events (SADEs). Secondary endpoints include primary and secondary patency rates, change in Rutherford classification, and freedom from amputation at 3 and 12 months.

DISCUSSION

The BYCROSS atherectomy system may be a novel device for the minimally invasive treatment of prolonged calcified lesions previously reserved for bypass surgery. This national prospective multicenter observational study could represent another step in demonstrating the efficancy and safety of this device for treatment of PAD.

TRIAL REGISTRATION

#DRKS00029947 (who.int). PROTOCOL APPROVAL ID: #22-0047(Ethics Committee at Ludwig-Maximilians-University Munich).

Gender disparities in patients with aortoiliac disease requiring open operative intervention

OBJECTIVE

Peripheral artery disease is known to affect males and females in different proportions. Disparate surgical outcomes have been quantified after endovascular aortic aneurysm repair, arteriovenous fistula creation, and treatment of critical limb ischemia. The aim of this study is to objectively quantify the sex differences in outcomes in patients undergoing open surgical intervention for aortoiliac occlusive disease.

METHODS

Patients were identified in the aortoiliac occlusive disease Vascular Quality Initiative database who underwent aorto-bifemoral bypass or aortic thromboendarterectomy as determined by Current Procedural Terminology codes between 2012 and 2019. Patients with a minimum of 1-year follow-up were included. Risk differences (RDs) by sex were calculated using a binomial regression model in 30-day and 1-year incidence of mortality and limb salvage. Additionally, incidence of surgical complications including prolonged length of stay (>10 days), reoperation, and change in renal function (>0.5 mg/dl rise from baseline), were recorded. Inverse probability weighting was used to standardize demographic and medical history characteristics. Multivariate logistic regression models were employed to conduct analyses of the before mentioned clinical outcomes, controlling for known confounders.

RESULTS

Of 16,218 eligible patients from the VQI data during the study period, 6538 (40.3%) were female. The mean age, body mass index, and race were not statistically different between sexes. Although there was no statistically significant difference detected in mortality between males and females at 30 days postoperatively, females had an increased crude 1-year mortality with an RD of 0.014 (95% confidence interval, 0.01-0.02; P value < .001. Males had a higher rate of a postoperative change in renal function with an RD of -0.02 (95% confidence interval, -0.03 to -0.01; P < .001).

CONCLUSIONS

Although there was no sex-based mortality difference at 30 days, there was a statistically significant increase in mortality in females after open aortoiliac intervention at 1 year based on our weighted model. Male patients are statistically significantly more likely to have a decline in renal function after their procedures when compared with females. Postoperative complications including prolonged hospital stay, reoperation, and wound disruption were similar among the sexes, as was limb preservation rates at 1 year. Further studies should focus on elucidating the underlying factors contributing to sex-based differences in clinical outcomes following aortoiliac interventions.

A sex-based analysis of 5-year outcomes following stenting for the treatment of aorto-iliac occlusive disease

OBJECTIVES

The aim of this study was to evaluate the impact of sex on mid-term outcomes following stenting for aorto-iliac occlusive disease (AIOD).

METHODS

The Covered versus Balloon Expandable Stent Trial (COBEST) compared the safety and efficacy of the covered stent (CS) with those of the bare metal stent (BMS) in the treatment of hemodynamically significant AIOD. It was identified that CS provided a significant benefit. The primary endpoint of our analysis was the rate of primary patency 5 years following stenting for AIOD (inclusive of both CS and BMS) in both sexes.

RESULTS

Of the 168 lesions treated, 103 (61%) were present in men and 65 (39%) were present in women. Of the concomitant comorbidities, diabetes mellitus was significantly more common in women (17.5% vs 41.5%, p = .006). Although chronic limb threatening ischemia (CLTI) at the time of intervention was more common in women, the difference was not significant (16.5% vs 24.6%, p = .395). Sex was not associated with the primary patency rate (male; 0.70, 95% confidence interval [CI]: 0.23-2.19, p = .543). When considering both male sex and the utilization of BMS, no significant impact was found on the primary patency rate (hazard ratio [HR]: 3.43, 95% CI: 0.69-17.10, p = .133). All-cause mortality at 60 months was 22.6% in men compared to 19.4% in women (p = .695).

CONCLUSIONS

No significant difference was identified in the primary patency rate between the sexes. Further investigation is warranted to ascertain whether sex-specific interventional guidelines are required in this regard.

Angioscopic and histopathological findings of in-stent restenosis in external iliac artery

Little has been reported on the angioscopic and histopathological findings of in-stent restenosis (ISR) in the iliac artery. Here, we report a case of a male patient in his 70s who showed recurrent ISR in the right external iliac artery. We observed the ISR lesions with not only an intravascular ultrasound (IVUS) but also an angioscopy and a biopsy to clarify the mechanism of ISR. These imaging and histopathological findings showed neointimal hyperplasia, and we performed endovascular therapy with covered stent placement to prevent neointimal formation. Not only the IVUS but also the angioscopic and histopathological findings were helpful to clarify the mechanism of ISR and to determine the treatment plan.

Effectiveness of Unsupervised Exercise Therapy After Endovascular Treatment for an Iliac Occlusive Lesion

Objective

Exercise therapy has acceptable outcomes for patients with intermittent claudication (IC), but there are few reports on the results of continuous unsupervised exercise therapy after endovascular treatment (EVT) for an iliac lesion. The aim of this study is to analyze the long-term outcomes of unsupervised exercise therapy for patients after EVT.

Material and Methods

A retrospective analysis was performed in 76 patients (93 limbs) with IC who underwent iliac EVT from 2012 to 2020 at our hospital. Maintenance of unsupervised exercise therapy was evaluated at 6 months after EVT. Long-term outcomes such as primary patency, clinically driven target lesion revascularization (CD-TLR), survival, and major adverse cardiovascular events (MACE) were compared between patients who continued (cET group) or discontinued (dET group) unsupervised exercise therapy.

Results

A total of 28 patients (37%) continued unsupervised exercise therapy until 6 months after EVT for an iliac lesion. There were no differences in patient background and procedural details between the cET and dET groups. The follow-up rate was 96% in a median follow-up period of 35 [25 – 42] months. The mean exercise time in the cET group was 52 ± 18 minutes daily, with a mean frequency of 5.8 ± 1.1 days per week. The median step count in the cET group was 5559 ± 2908 steps daily. At 3 years, the cET group had significantly higher rates for primary patency (97% vs 71%, P = .002), and freedom from CD-TLR (97% vs 79%, P = .007); and a tendency for higher survival (100% vs 94%, P = .074), and higher freedom from MACE (89% vs 73%, P = .12).

Conclusion

The findings of this study suggested superior long-term outcomes, including primary patency, freedom from CD-TLR, survival, and freedom from MACE, in patients who maintained continuous unsupervised exercise therapy after EVT.

Covered Stents vs. Angioplasty for Common Iliac Artery In Stent Restenosis: A Retrospective Comparison

OBJECTIVE

The optimal endovascular treatment for common iliac artery in stent re-stenosis has yet to be assessed. Treatment options include, among others, angioplasty alone and repeated stenting with covered stents.

METHODS

This study retrospectively compared patency and target lesion revascularisation of these treatments. All patients who underwent endovascular treatment of common iliac artery in stent re-stenosis between 2007 and 2017 were included retrospectively. The primary end point was freedom from re-stenosis. Secondary endpoints were target lesion revascularisation rate (TLR) and freedom from occlusion during follow up.

RESULTS

Seventy-four interventions were included, consisting of 37 angioplasties and 37 covered stent placements in 57 patients. Freedom from re-stenosis at four years was 72.6% (95% confidence interval [CI] 51.8% - 88.7%) in the covered stent group vs. 43.5% (95% CI 25.9% - 59.8%) in the percutaneous transluminal angioplasty (PTA) group (p = .003). The target lesion revascularisation (TLR) rate was 16.4% (95% CI 7.1% - 35.6%) and 43.6% (95% CI 28.0% - 63.2%) respectively (p = .020). There was no difference in freedom from occlusion; this was 90.8% (95% CI 73.9% - 97.0%) in the covered stent group and 79.1% (95% CI 58.4% - 90.3%) in the PTA group (p = .49). The difference in freedom from re-stenosis and TLR remained significant after sensitivity and multivariable analyses.

CONCLUSION

Covered stents offer better outcomes for common iliac artery in stent re-stenosis than angioplasty alone.

Mechano-chemo-biological Computational Models for Arteries in Health, Disease and Healing: From Tissue Remodelling to Drug-eluting Devices

This review aims to highlight urgent priorities for the computational biomechanics community in the framework of mechano-chemo-biological models. Recent approaches, promising directions and open challenges on the computational modelling of arterial tissues in health and disease are introduced and investigated, together with in silico approaches for the analysis of drug-eluting stents that promote pharmacological-induced healing. The paper addresses a number of chemo-biological phenomena that are generally neglected in biomechanical engineering models but are most likely instrumental for the onset and the progression of arterial diseases. An interdisciplinary effort is thus encouraged for providing the tools for an effective in silico insight into medical problems. An integrated mechano-chemo-biological perspective is believed to be a fundamental missing piece for crossing the bridge between computational engineering and life sciences, and for bringing computational biomechanics into medical research and clinical practice.

Long-term results of endovascular reconstruction for aortoiliac occlusive disease

Background

Open surgery is the gold standard for the treatment of aortoiliac occlusive disease (AIOD). Endovascular therapy has emerged as an attractive alternative for AIOD due to its minimal invasiveness. The aims of the present study were to investigate the long-term patency of endovascular treatment and to compare the outcomes of Transatlantic Inter-Society Consensus II (TASC II) A/B and C/D lesions.

Methods

Patients with AIOD (n=156) were enrolled in this retrospective cohort study. Patency rates were assessed at 12, 36, and 60 months after the procedure. Parameters for comparisons between TASC II A/B and C/D lesions included primary patency, secondary patency, freedom from target lesion revascularization (TLR), the technical success rate, the rate of complications, and risk factors for in-stent restenosis.

Results

For all patients, the technical success rate was 98.7%, the complication rate was 4.5%, and the mean follow-up period was 35.7 months. At 12, 36, and 60 months after the procedure, the primary patency rates were 96.5%, 88.3%, and 80.4%, respectively. The secondary patency rates were 99%, 96.4%, and 88%, respectively. The rates of freedom from TLR were 97.5%, 91.6%, and 89.6%. No significant differences were observed between A/B and C/D lesions in terms of primary patency (P=0.443), secondary patency (P=0.393), or freedom from TLR (P=0.481).

Conclusions

Endovascular reconstruction is effective and safe for AIOD, and should be the first-line treatment option for patients with TASC II A-D aortoiliac lesions.

Bare Stents for Iliac Chronic Total Occlusions ("TELIS"): A Prospective Cohort Study with a Midterm Follow-up

BACKGROUND

This study aims to assess primary bare stenting for iliac chronic total occlusions (CTOs) with midterm follow-up.

METHODS

From April 2013 to May 2016, all patients presenting with symptomatic iliac CTO were treated endovascularly and included in a prospective single-center cohort. Common iliac CTOs were treated with balloon-expandable bare-metal stents. External iliac lesions were treated with bare self-expandable nitinol stents. Primary end point was primary sustained clinical improvement. A total of 49 iliac CTOs were treated in 46 patients.

RESULTS

A total of 22 lesions were located at the level of the common iliac artery (45%), 20 at the external iliac artery (41%), and 7 extending to both (14%). Mean stenting length was 114.4 ± 49.8 mm. Technical success was 98%. Primary sustained clinical improvement was achieved for 93.4 ± 3.7% of patients at 12 months and 87.7 ± 5.2% at 24 months. Three in-stent thrombosis were observed with no restenosis in the remaining patients at 24 months. Freedom from target lesion revascularization was 93.3% ± 3.7% at 24 months. Three stent fractures were noted, none were symptomatic. Mean quality of life (EQ5D-3L) was significantly improved at 24 months (71.2 ± 20.3 vs. 52.4 ± 22.6, P = 0.001).

CONCLUSIONS

Our results showed that primary bare-metal stenting for iliac CTO is safe and efficient at 24 months and could be considered as a first-line strategy.

Acute and Midterm Outcomes of Antegrade vs Retrograde Crossing Strategies for Endovascular Treatment of Iliac Artery Chronic Total Occlusions

Purpose: To examine whether an antegrade or retrograde crossing strategy for treatment of iliac artery chronic total occlusions (CTOs) is associated with differences in procedural or midterm outcomes. Materials and Methods: A dual-center retrospective cohort study was conducted in 168 patients (mean age 66.4±10.6 years; 116 men) treated for CTOs in 110 common iliac arteries (CIA), 52 external iliac arteries (EIA), and 26 combined CIA/EIAs. Logistic regression models were developed to determine the association between crossing strategy and procedural complications, 1- and 3-year target lesion revascularization (TLR), and major adverse limb events (MALE). Results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: An initial antegrade strategy was more common for EIA CTOs (p<0.005), and an initial retrograde strategy was more often used in CIA (p<0.005) and combined CIA/EIA (p<0.005) CTOs. Crossover to an alternate approach was required in 27.6% of initial antegrade attempts and 9.6% of initial retrograde attempts. EIA CTOs were the most likely lesions to be treated successfully with the initial attempt (either strategy). In all, 123 (65.4%) lesions were successfully crossed with a final retrograde approach and 65 with a final antegrade approach. Overall target lesion success was high for both groups (95.1% vs 93.2%, p=0.456). Lesions treated with a final retrograde approach were shorter (75.3±34.9 vs 87.6±31.3 mm, p=0.005) and were more likely to be treated with a reentry device (34.2% vs 9.2%, p<0.001) and with balloon-expandable stents (39.2% vs 17.7%, p=0.005). The final antegrade approach was associated with a lower risk of target lesion complications (OR 0.07, 95% CI 0.01 to 0.81, p=0.034). The two crossing approaches were associated with similar estimates of 1- and 3-year TLR and MALE. Conclusion: A final antegrade approach was associated with lower rates for complications but the 2 approaches were similar in terms of lesion success, TLR, and MALE. The EIA CTOs were more likely to be treated with an antegrade approach and more likely to be crossed successfully with the initial approach irrespective of the crossing direction.

The use of an occlusion perfusion catheter to deliver paclitaxel to the arterial wall

AIM

Nonstent drug delivery platforms have recently emerged as an alternative treatment of peripheral arterial disease. Perfusion catheters have the potential to directly deliver antiproliferative agents to the medial arterial layer to prevent restenosis. The purpose of this study was to therefore determine the effectiveness of a perfusion catheter to deliver paclitaxel, a proven antiproliferative agent, to combat restenosis.

METHODS

A benchtop model was utilized to determine the varying parameters of a novel occlusion perfusion catheter to maximize paclitaxel delivery using pharmacokinetic evaluation and fluorescent microscopy. Parameters tested included concentration of paclitaxel, delivery pressure, duration of delivery, and the use of an excipient. In addition, bilateral rabbit iliac arteries were treated with the perfusion catheter and pharmacokinetic evaluation performed at 1 hour, 1 day and 3 days.

RESULTS

Benchtop testing demonstrated uniform and circumferential penetration of paclitaxel within the treated arteries. The results of the ex vivo test identified two groups with and without an excipient with similar loading conditions (with excipient: 15.4±8.6 ng/mg vs without excipient: 8.9±6.9 ng/mg, P=.77). The in vivo pharmacokinetic analysis of these two groups demonstrated the use of contrast agent increased arterial paclitaxel levels and maintained initial paclitaxel dosing up to 3 days (With excipient: 1 hour: 107±62 ng vs 3 days: 40±23 ng, P=.824; No excipient: 1 hour: 247±120 ng vs 3 days: 2.92±2.9 ng, P=.009).

CONCLUSIONS

These results demonstrate the feasibility to deliver paclitaxel directly to the medial layer of an artery via a perfusion catheter.

Creation of an Extraluminal Arterial Bypass Graft Using a Commercially Available Self-Expanding Stent Graft: Feasibility Study in a Porcine Model

PURPOSE

The purpose of this study was to assess the technical feasibility of ultrasound-guided endovascular creation of a percutaneous extraluminal arterial bypass graft without a surgically created arterial anastomosis.

MATERIALS AND METHODS

Nine swine were utilized for this IACUC-approved study using a carotid bypass model in swine. Using sonographic guidance, percutaneous access was obtained to the proximal and distal common carotid artery. A self-expanding stent graft was advanced through the proximal carotid access site, tunneled subcutaneously, then advanced through the distal carotid access site, and deployed. The stent grafts were monitored weekly for patency using ultrasound. Angiography was performed at 4 weeks to evaluate for graft patency. Gross pathologic analysis was performed on the explanted stent grafts.

RESULTS

In eight out of the nine swine (89%), percutaneous extraluminal bypass graft creation was technically successful, with brisk flow through the stent graft to the distal circulation, complete exclusion of the bypassed segment of carotid artery, and no extravasation. The technical failure was due to stent graft maldeployment. Of the six swine evaluated for patency, four grafts were patent at the 4-week end point. Both occluded stent grafts were due to extraluminal extrusion of one end, likely related to neck movement and growth in neck length.

CONCLUSION

The percutaneous arterial bypass technique had a high technical success rate and a graft patency rate of 67% at 4 weeks, with early occlusions possibly related to limitations of the animal model.

Drug-Eluting vs Standard Balloon Angioplasty for Iliac Stent Restenosis: Midterm Results

PURPOSE

To assess the effectiveness of drug-eluting balloon (DEB) angioplasty for the treatment of iliac artery in-stent restenosis (ISR).

METHODS

Data from 18 patients (mean age 59.3±9.6 years; 11 men) treated with DEB for iliac ISR between October 2009 and August 2013 were retrospectively evaluated and compared with a control group of 22 patients (mean age 66.7±11.8 years; 16 men) treated with standard balloon angioplasty (BA). Primary endpoint of the study was the primary patency rate at 12 months. Secondary endpoints were 30-day and overall mortality, sustained clinical improvement [ankle-brachial index (ABI) and Rutherford category] and clinically driven target lesion revascularization (TLR). Follow-up examinations were performed by clinical examination, color duplex ultrasound, and ABI measurement at 12 months.

RESULTS

Mean length of the 21 lesions in the DEB group was 27.1±19.2 mm vs 20.0±11.4 mm for the 25 lesions in the BA group (p=0.508), while the grade of restenosis was 70.4%±18.4% and 64.0%±16.1% (p=0.255), respectively. Primary patency rates were 90.5% vs 85.7% at 6 months and 71.4% vs 75.6% at 12 months for DEB and BA, respectively (p=0.784). Five BA patients died during follow-up for reasons unrelated to the procedure, while no patient in the DEB group died (p=0.035). In both groups, Rutherford category and ABI significantly improved compared to pretreatment levels; there were no differences between the groups regarding these variables (p=0.367 and p=0.898, respectively). The TLR rate was 28.6% (6/21) in the DEB group and 20.0% (4/20) in the BA cohort (p=0.434).

CONCLUSION

Treatment of iliac ISR using DEBs is a safe procedure, with results comparable to BA treatment. Because of the limited number of patients in this study, further investigation of a larger cohort with longer follow-up is needed to define the role of DEBs in the treatment of iliac ISR.

Korean Guidelines for Interventional Recanalization of Lower Extremity Arteries

Peripheral arterial occlusive disease caused by atherosclerosis can present with intermittent claudication or critical limb ischemia. Proper diagnosis and management is warranted to improve symptoms and salvage limbs. With the introduction of new techniques and dedicated materials, endovascular recanalization is widely performed for the treatment of peripheral arterial occlusive disease because it is less invasive than surgery. However, there are various opinions regarding the appropriate indications and procedure methods for interventional recanalization according to operator and institution in Korea. Therefore, we intend to provide evidence based guidelines for interventional recanalization by multidisciplinary consensus. These guidelines are the result of a close collaboration between physicians from many different areas of expertise including interventional radiology, interventional cardiology, and vascular surgery. The goal of these guidelines is to ensure better treatment, to serve as a guide to the clinician, and consequently, to contribute to public health care.

Drug-eluting balloons to treat iliac in-stent restenosis

BACKGROUND

To report our experience in the use of drug-eluting balloons (DEBs) for the treatment of symptomatic iliac in-stent restenosis (ISR).

CASE REPORTS

Six patients underwent treatment using DEBs for iliac ISRs in our centers between September 2011 and May 2014. The patients were predominantly women (4 of 6, 66.7%) with a mean age of 67.2 years (range, 46-75 years). Technical success was achieved in all cases. During the follow-up (mean duration, 15.5 months; range, 3-30 months), healing of the lesions/relief of symptoms was obtained in 5 of 6 cases (83.3%). Estimated 2-year rates of overall patency and limb salvage were 100%.

CONCLUSIONS

The use of DEBs in the treatment of iliac ISR is safe and effective. The early and 2-year outcomes are promising. However, further experience with larger patient groups is needed.

Self-expanding stents and aortoiliac occlusive disease: a review of the literature

The treatment of symptomatic aortoiliac occlusive disease has shifted from open to endovascular repair. Both short- and long-term outcomes after percutaneous angioplasty and stenting rival those after open repair and justify an endovascular-first approach. In this article, we review the current endovascular treatment strategies in patients with aortoiliac occlusive disease, indications for primary and selective stenting in the iliac artery, and physical properties and future perspectives of self-expanding stents.

Endovascular treatment for unilateral chronic total occlusions of the iliac artery categorized as TASC II type D lesions

PURPOSE

To compare the results of endovascular treatment for unilateral iliac occlusion in types B and D, and confirm its validity for type D.

METHODS

Between 2000 and 2011, 108 patients underwent endovascular treatment for unilateral iliac occlusion. 77 were categorized as type B for occlusion of common iliac artery (CIA) or external iliac artery (EIA) and 31 were categorized as type D for occlusion of both CIA and EIA. The initial success rates, procedure time, penetration time, amount of contrast media used, complication rates, and cumulative primary patency rates were determined and compared between these groups.

RESULTS

Between type D and B groups, the initial success rates were 87.1 % (type D) and 89.6 % (type B) (p = 0.9316). The procedure time was 137.0 ± 55.5 and 97.2 ± 47.2 min (p < 0.05). The penetration time was 49.1 ± 40.6 and 31.6 ± 30.1 min (p < 0.05). The amount of contrast agent used was 193.9 ± 103.1 and 156.5 ± 85.0 ml (p = 0.0722). The complication rates were 6.5 and 3.9 % (p = 0.8491). The cumulative primary patency rates, at 1, 3, and 5 years were 91, 85, and 85 % and 100, 96, and 93 %.

CONCLUSION

Endovascular treatment can be indicated for unilateral occlusion of both CIA and EIA categorized as type D.

The influence of gender on patency rates after iliac artery stenting

OBJECTIVE

The purpose of this study was to investigate the influence of gender on the long-term outcome after iliac artery stenting and to assess gender-specific differences of the influence of risk factors on treatment success and patency rates.

METHODS

Between January 2000 and December 2006, 404 percutaneous transluminal angioplasties with primary stent deployment for symptomatic iliac artery occlusive disease were performed at our center. These included 128 interventions in women and 276 interventions in men.

RESULTS

Whereas average age was significantly higher (65.9 ± 12.9 years; P = .007) and arterial hypertension more frequent (60.9% vs 49.3%; P = .032) in women, hyperuricemia (7.0% vs 14.1%; P = .047) and a positive smoking status (61.7% vs 74.3%; P = .014) were more frequently observed in men. Fontaine stage was more advanced (stages III and IV) in women than in men (P = .028; P < .001). Technical success was 97.7% in women and 99.3% in men. Overall complication rate was higher in women compared with men (P = .002), mostly caused by access site hematomas (4.7% vs 0.4%) and pseudoaneurysms (8.6% vs 2.5%). Patients were followed up for 45.0 ± 33.3 months. Restenosis developed in 16.8% of cases in women and in 14.6% of cases in men and was treated in 73.7% by an endovascular approach. Primary patency rates at 1, 3, 5, and 7 years were 90.3%, 77.2%, 60.2%, and 46.4% in women and 89.9%, 71.5%, 63.6%, and 59.7% in men, respectively (P = .524; log-rank, .406). Secondary patency rates were 97.2%, 91%, 81.5%, and 70.3% in women and 97.1%, 89.1%, 82.6%, and 78% in men, respectively (P = .959; log-rank, .003). Multivariate analysis identified lower age as the only independent risk factor for recurrent disease in both groups. Age-defined subgroup analysis showed a restenosis/reocclusion rate of 23.9% in men and 22.1% in women older than 63.5 years (P = .861) but 32.1% in men and 49.1% in women younger than that (P = .034).

CONCLUSIONS

Our data suggest that although women are older and present with a more advanced stage of peripheral arterial occlusive disease, endovascular therapy is equally effective irrespective of gender. Surprisingly, the subgroup of young female patients had a specifically poor outcome.

Short- and midterm results of iliac artery stenting for flush occlusion with the assistance of an occlusive contralateral iliac artery balloon

BACKGROUND

Endovascular treatment of flush iliac artery occlusion remains a challenge and is most often performed using open surgery. We report the outcomes of 10 cases that were successfully recanalized endovascularly with the assistance of a contralateral occlusive balloon.

METHODS

A retrospective review of patients undergoing iliac artery stenting was performed at a single institution. Technical success, short- and midterm patency, and 30-day complications are reported.

RESULTS

Ten patients were identified. Technical success was 100% when a brachial approach was used. Retrograde recanalization was attempted in 3 cases. Reentry into the aorta could not be achieved in 1 case. The aorta was entered above the inferior mesenteric artery (IMA) in the other 2 cases, and the decision was made to attempt a brachial approach to avoid stenting above the IMA. There were no dissections or perforations. Two patients developed brachial access complications, but only 1 required operative repair for a pseudoaneurysm. Nine patients (90%) remained patent at a mean follow-up of 14.6 months (range 9-24 months). One patient presented 9 months later with iliac artery stent and lower extremity bypass thromboses, which resulted in an amputation. There were no deaths in this series.

CONCLUSIONS

Iliac stenting for flush iliac artery occlusion can be achieved with this technique with encouraging short- and midterm results and minimal morbidity.

Sustained patency and clinical improvement following treatment of atherosclerotic iliac artery disease using the Assurant cobalt iliac balloon-expandable stent system

PURPOSE

To report the outcome of the ACTIVE (Use of the Assurant Cobalt Iliac Stent System in the Treatment of Iliac Vessel Disease) study (ClinicalTrials.gov Identifier: NCT00753337), which was designed to determine the safety and effectiveness of the next-generation Assurant cobalt chromium balloon-expandable stent in symptomatic patients with iliac occlusive disease.

METHODS

This prospective, multicenter, single-arm study enrolled 123 symptomatic (Fontaine class II or III) patients (69 men; mean age 65.5±10.6 years) with 159 de novo or restenotic lesions (length ≤100 mm) in the common or external iliac arteries. Objective measures of outcome were ankle or toe-brachial indexes, Fontaine class, and duplex ultrasound evaluations collected before the procedure and at 1 and 9 months. The primary endpoint of major adverse events (MAE) at 9 months was defined as device- and procedure-related death, target limb loss, or clinically-driven target lesion or target vessel revascularization (TLR/TVR).

RESULTS

At 9 months, the rate of MAE was 0.8% with 1 TLR and 99.2% primary patency. There were no device- or procedure-related deaths or target limb amputations. The ankle-brachial index increased by 0.2±0.2 at 1 and 9 months. There was an improvement in the Fontaine classification of claudication for the majority of patients, accompanied by significant and sustained improvements in walking speed, distance, and stair climbing.

CONCLUSION

The balloon-expandable Assurant cobalt chromium iliac stent demonstrated an excellent safety profile and sustained patency associated with marked improvements in objective and functional measures of patency.

Mid-term outcomes following endovascular re-intervention for iliac artery in-stent restenosis

OBJECTIVES

We sought to evaluate the procedural characteristics and clinical outcomes of endovascular repair for iliac artery (IA) in-stent restenosis (ISR).

BACKGROUND

An increasing percentage of patients with complex IA occlusive disease are treated with an endovascular approach, but the outcomes of IA-ISR have not been well described.

METHODS

We analyzed all endovascular procedures for treatment of IA-ISR performed at our institution between July 2006-December 2010. The primary outcome was primary patency, defined as <50% stenosis as assessed by clinical examination and duplex ultrasonography (DUS).

RESULTS

Forty-one lesions in 24 patients who underwent repeated endovascular intervention for treatment of IA-ISR. Most lesions were unilateral and involved the common IA (66%). The mean length of ISR was 30.1 ± 14.1 mm with type I (focal) and II (diffuse) ISR occurring with the greatest frequency (34% and 39%, respectively). All patients underwent balloon angioplasty; adjunctive stenting zwas performed in 27 (66%) of the lesions. Type II ISR lesions more frequently required stenting (13/16 lesions, P = 0.02 compared with other patterns of ISR). Procedural success was 100% with a mean gain of 0.13 in the ankle-brachial index (P = 0.001). The 6- and 12-month primary patency rates were 96% and 82%, respectively. The 12-month primary-assisted patency rate was 90% with clinically driven target lesion revascularization (TLR) in three patients.

CONCLUSIONS

Endovascular treatment of IA-ISR using an approach of balloon angioplasty followed by selective stenting is associated with high-patency rates and low rates of TLR at 1 year.

DISCOVER: Dutch Iliac Stent trial: COVERed balloon-expandable versus uncovered balloon-expandable stents in the common iliac artery: study protocol for a randomized controlled trial

BACKGROUND

Iliac artery atherosclerotic disease may cause intermittent claudication and critical limb ischemia. It can lead to serious complications such as infection, amputation and even death. Revascularization relieves symptoms and prevents these complications. Historically, open surgical repair, in the form of endarterectomy or bypass, was used. Over the last decade, endovascular repair has become the first choice of treatment for iliac arterial occlusive disease. No definitive consensus has emerged about the best endovascular strategy and which type of stent, if any, to use. However, in more advanced disease, that is, long or multiple stenoses or occlusions, literature is most supportive of primary stenting with a balloon-expandable stent in the common iliac artery (Jongkind V et al., J Vasc Surg 52:1376-1383,2010). Recently, a PTFE-covered balloon-expandable stent (Advanta V12, Atrium Medical Inc., Hudson, NH, USA) has been introduced for the iliac artery. Covering stents with PTFE has been shown to lead to less neo-intimal hyperplasia and this might lower restenosis rates (Dolmatch B et al. J Vasc Interv Radiol 18:527-534,2007, Marin ML et al. J Vasc Interv Radiol 7:651-656,1996, Virmani R et al. J Vasc Interv Radiol 10:445-456,1999). However, only one RCT, of mediocre quality has been published on this stent in the common iliac artery (Mwipatayi BP et al. J Vasc Surg 54:1561-1570,2011, Bekken JA et al. J Vasc Surg 55:1545-1546,2012). Our hypothesis is that covered balloon-expandable stents lead to better results when compared to uncovered balloon-expandable stents.

METHODS/DESIGN

This is a prospective, randomized, controlled, double-blind, multi-center trial. The study population consists of human volunteers aged over 18 years, with symptomatic advanced atherosclerotic disease of the common iliac artery, defined as stenoses longer than 3 cm and occlusions. A total of 174 patients will be included. The control group will undergo endovascular dilatation or revascularization of the common iliac artery, followed by placement of one or more uncovered balloon-expandable stents. The study group will undergo the same treatment, however one or more PTFE-covered balloon-expandable stents will be placed. When necessary, the aorta, external iliac artery, common femoral artery, superficial femoral artery and deep femoral artery will be treated, using the standard treatment. The primary endpoint is absence of binary restenosis rate. Secondary endpoints are reocclusion rate, target-lesion revascularization rate, clinical success, procedural success, hemodynamic success, major amputation rate, complication rate and mortality rate. Main study parameters are age, gender, relevant co-morbidity, and several patient, disease and procedure-related parameters.

TRIAL REGISTRATION

Dutch Trial Register, NTR3381.

Bifurcated endograft in aortoiliac type C and D lesions: long-term results

PURPOSE

To report long-term outcome when using a bifurcated aortic endograft for treatment of aortoiliac occlusive disease (AIOD) in Trans Atlantic Inter Society Consensus (TASC) classification C and D patients.

MATERIALS AND METHODS

Between May 2001 and May 2009, 14 patients (11 men, 3 women) with aortoiliac TASC C and D type lesions and a mean age of 59 years ± 10 (range 41-73 years) were treated using a bifurcated aortic endograft. Although these patients were young, all were considered at high surgical risk. Patients were followed up clinically and by computed tomography (CT) every 3 months for 1 year and yearly thereafter.

RESULTS

Endoprosthesis placement was performed in all patients with a technical success rate of 100%. There were no amputations or deaths at 30 days after the procedure. The mean follow-up was 62 months (range 11-96 months). One patient was lost during follow-up at 11 months, and another patient died of a nonrelated cause after 49 months. A single limb occlusion of the prosthesis was seen in two patients at 2 months and 7 months; both were successfully treated by intraarterial fibrinolysis. At a mean follow-up of 62 months, primary patency was 85.7%, and secondary patency was 100%.

CONCLUSIONS

This series shows promising long-term results following the use of a bifurcated aortic endograft for treatment of AIOD TASC C and D type lesions. Bifurcated aortic endograft is a good minimally invasive alternative to open surgery in high surgical risk patients.

Heavily calcified occlusive lesions of the iliac artery: long-term patency and CT findings after stent placement

PURPOSE

To evaluate the influence of heavy calcification on iliac arterial stent expansion and patency and to define the spatial relationship between the stent and heavy calcifications on computed tomography (CT).

MATERIALS AND METHODS

Thirteen patients (11 men, two women; mean age, 66.5 y) with 14 heavily calcified iliac arteries received primary stent treatment between 1998 and 2008. Anatomic success was defined by less than 30% residual stenosis on final follow-up CT angiography. Hemodynamic success was defined as an increase in the ankle-brachial index (ABI) of at least 0.15 versus baseline. Clinical success was defined by achievement of clinical improvement of at least one clinical category. Stent patency; anatomic, hemodynamic, and clinical success rate; morphology of heavy calcifications; calcium score; and stent geometry were evaluated.

RESULTS

Stents were successfully inserted in all cases. During a mean follow-up of 33.6 months (range, 8-55 mo), the stent-implanted iliac arteries remained anatomically patent in all patients on final follow-up. The anatomic, hemodynamic, and clinical success rates were 28.6%, 60%, and 78.6%, respectively. Mean ABIs were 0.68 ± 0.22 before the procedure and 0.91 ± 0.23 after the procedure (P = .021). Mean luminal stenosis measurements were 77.9% before the procedure and 47.9% after the procedure (P = .008).

CONCLUSIONS

Iliac stents in heavily calcified lesions showed hemodynamically significant residual stenosis in a considerable number of cases. However, stent patency was not affected even with incomplete expansion of the stent.

Preprocedural evaluation and endovascular treatment of iliofemoral artery disease without contrast media for patients with pre-existing renal insufficiency

BACKGROUND

Generally, both the preprocedural evaluation and endovascular therapy (EVT) for lower limb arteries require contrast media that is harmful for patients with chronic renal insufficiency. In the present study these procedures were performed without using nephrotoxic contrast media in patients with preexisting renal insufficiency and iliofemoral artery disease.

METHODS AND RESULTS

The 36 consecutive patients with chronic renal insufficiency underwent preprocedural evaluation with duplex examination, magnetic resonance angiography (MRA) without contrast media, and plain computed tomography (CT). A total of 51 lesions were treated using intravascular ultrasound (IVUS) without contrast media. The overall technical success was 100% without any complications. Pre- and postprocedural ankle-brachial indices changed from 0.59 ± 0.23 to 0.92 ± 0.14. The mean serum creatinine concentration before and after treatment, and 3 months after treatment did not change (2.1 ± 1.4, 2.0 ± 1.4, and 2.1 ± 1.6 mg/dl, respectively). The overall 3-month survival rate and limb salvage rate was 100%.

CONCLUSIONS

EVT comprising duplex, MRA, and CT for preprocedural evaluation and IVUS-guided procedure is feasible and may avoid intra-arterial contrast injection in selected patients deemed at high risk for renal failure from nephrotoxic contrast material.

Stent-triggered 'electric shock' during leg bending 2 years after emergency iliac artery percutaneous revascularization

We report a case of a 41-year-old woman who underwent surgical removal of an uterine leiomyoma, complicated by accidental injury of the left external iliac artery, treated by suturing. A few days after the intervention the patient was treated with emergency percutaneous stent implantation for acute thrombotic occlusion of the external iliac artery. Two years later, the patient began to complain of pain in the left leg, as an 'electric shock' sensation in the leg during squatting and leg adduction on the trunk. An angiographic control showed a critical in-stent restenosis at the level of a misplaced stent. Thus the patient was submitted to surgical exploration and stent removal.