Long-term Results After Primary Stenting of Distal Aortic Stenosis

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.

Low-profile primary stent placement for the treatment of focal calcified ulcerated stenosis in the infrarenal aorta

PURPOSE

To analyze the immediate and midterm success of low-profile stent placement in calcified ulcerated lesions of the infrarenal aorta in patients with arterial occlusive disease.

MATERIALS AND METHODS

In this prospective case series, 13 symptomatic patients (eight men, five women; mean age, 64.8 years +/- 12.1; age range, 44-84 years) with focal calcified ulcerated stenoses of the infrarenal aorta were treated with stent placement by using a low-profile technique in a radiology intervention center during a 4-year period. Clinical examinations and duplex ultrasonography were used to evaluate the stents? patency and clinical success. Kaplan-Meier graphs were calculated to analyze the freedom-of-symptom rate.

RESULTS

The initial technical success rate was 92% (12 of 13 patients). Due to extended calcifications, a residual stenosis of 50%-60% remained in one patient. No peri-interventional complications occurred. The mean follow-up was 26 months (range, 5-53 months). During follow-up, one patient had a restenosis after 7 months and presented clinically with Fontaine stage IIb. Two patients had iliac and/or femoral stenoses, and both presented with Fontaine stage IIb. One patient's symptoms originated from the lumbar spine. Primary patency and primary clinical success rates were 85% and 69%, respectively. According to Kaplan-Meier tables, the freedom-from-symptom rates were 92%, 84%, 73%, and 63% at 0, 7, 12, and 21 months, respectively.

CONCLUSIONS

Low-profile stent placement in calcified, ulcerated lesions of the infrarenal aorta is an effective and safe treatment for symptomatic stenoses in patients with arterial occlusive disease after a mean follow-up of 26 months.

[Rational minimally invasive treatment of pAOD: when should a conservative approach, PTA, or stent be chosen?]

In order to obtain optimal results and satisfied patients, rational therapy of pAOD should strictly follow national and international society guidelines. In particular cases an individual therapeutic concept seems justified beyond these guidelines. Based on clinical data and driven by costs, aortic and iliac lesions may be treated by PTA or selective stent placement with equal results; however, long-term data justify also primary, direct stenting. For treatment of infrainguinal and popliteal stenotic lesions primary stenting should be restricted to PTA failure (dissection, recoil, occlusion); except for treatment of extended lesions, primary stenting compared to PTA alone seems beneficial in terms of midterm patency. Endovascular procedures below the knee and at the toe should be limited to existing limb-threatening ischemia in order to save the extremity; whether PTA or stenting is advantageous has not yet determined.