Ulcerated plaques and focal aneurysms of iliac arteries: treatment with noncovered, self-expanding stents

Percutaneous Endovascular Stent-Graft Repair of Iliac Artery Aneurysms

Purpose:

To report a percutaneous technique for endovascular repair of iliac artery aneurysms using commercially available materials.

Methods:

Ten patients (9 males; mean age 65 ± 11 years) presented with 11 isolated iliac artery aneurysms; 3 patients were asymptomatic. Stent-grafts were customized for each patient from polytetrafluoroethylene grafts with Palmaz stents sutured at either end of the tube. The devices were delivered percutaneously through standard 14F sheaths and deployed by balloon dilation.

Results:

All iliac aneurysms were excluded without procedural incident. One patient with chronic renal insufficiency (baseline serum creatinine 1.9 mg/dL) experienced transient contrast-induced renal failure inhospital. The average hospital stay was 2.5 days (range 1 to 7). One vessel thrombosed 2 weeks following the procedure; the culprit stenosis at the site of arterial cannulation was dilated. One patient died of myocardial infarction at 6 weeks. The remaining eight grafts are patent and free of endoleak at a mean 14-month follow-up.

Conclusions:

This percutaneous technique appears to be an acceptable alternative to open surgical repair.

Endovascular treatment of obstructive iliac artery dissections

PURPOSE

To report our results from a study of the endovascular treatment of flow restricting chronic atherosclerotic or catheter-induced segmental iliac artery dissections with bare stents.

MATERIAL AND METHODS

Thirty symptomatic patients with 32 lesions, including chronic atherosclerotic (n = 21) and catheter-induced (n = 11) segmental arterial dissections, were treated with primary stenting. The common iliac artery was involved in 19 lesions and the external iliac artery in the remaining 13. Two patients had two lesions in the same vessel. Technical success was defined as restoration of the smooth contoured luminal patency with no more than 20% residual stenosis in diameter in atherosclerotic dissections associated with plaque formation or total obliteration of the false lumen in catheter-induced dissections. Complete relief of, or marked improvements in, presenting symptoms, or at least single category improvement, was assessed for clinical success.

RESULTS

Technical success rate was 100%. No procedure-related complications such as distal emboli or early occlusions were observed. Complete symptom relief was achieved in all patients with catheter-induced dissection and in all but three cases with chronic spontaneous atherosclerotic dissection. In two cases, occlusion of the stents occurred during the follow-up period. Clinical and radiological mean follow-up for 24 months (range 3-55) revealed patency of all other stented segments. Cumulative primary patency rate was 97% over 12 months and 90% over 24 months.

CONCLUSION

Endovascular treatment of chronic atherosclerotic and catheter-induced short obstructive iliac arterial dissections with bare stents is safe and effective. Patency of the diseased arterial segment with a smooth lumen can be sustained for an extensive period.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diameter changes in isolated iliac artery aneurysms 1 to 6 years after endovascular graft repair

OBJECTIVE

Precise diameter changes in iliac artery aneurysms (IAAs) after endovascular graft (EVG) repair are yet to be determined. This report describes the midterm size changes in isolated IAAs 13 to 72 months after treatment with an EVG.

METHODS

From January 1993 to April 1999, 31 patients with 35 true isolated IAAs (32 common iliac and 3 hypogastric) had these lesions treated with EVGs and coil embolization of the hypogastric artery or its branches. The EVG used in this study consisted of a balloon-expandable stent attached to a polytetrafluoroethylene graft. Contrast-enhanced spiral computed tomographic scans were performed at 3- to 6-month intervals to follow the aneurysms for change in diameter and endoleaks.

RESULTS

Thirty patients had a decrease in the size of their iliac aneurysms with EVG repair. All EVGs remained patent. All patients, except for one, were followed up for 13 to 72 months (mean, 31 months). The pretreatment aneurysm size ranged from 2.5 to 11.0 cm in diameter (mean, 4.6 +/- 1.62 cm). After EVG treatment, the aneurysms ranged from 2.0 to 8.0 cm in diameter (mean, 3.8 +/- 1.36 cm). The change in aneurysm diameter ranged from 0.5 to 3.1 cm (mean, 1.1 +/- 0.62 cm) with an average change of -0.516 +/- 0.01 cm/y for the first year. Five patients died of their intercurrent medical conditions during the follow-up period. One of the patients had a new endoleak and an increase in common iliac aneurysm size 18 months after EVG treatment, despite an early contrast-enhanced computed tomographic scan that showed no endoleak. This patient's aneurysm ruptured, and a standard open surgical repair was successfully performed. Another patient had a decrease in hypogastric aneurysm size after EVG treatment and no radiographic evidence of an endoleak, but eventually the aneurysm ruptured. He was successfully treated with a standard open surgical repair.

CONCLUSIONS

EVGs can be an effective treatment for isolated IAAs. Properly treated with EVGs, IAAs decrease in size. The enlargement of an IAA, even if no endoleak can be detected, appears to be an ominous sign suggestive of an impending rupture. IAAs that enlarge should be closely evaluated for an endoleak. If an endoleak is detected, it should be eliminated if possible. If an endoleak cannot be found, open surgical repair should be considered.

Midterm experience with the endovascular treatment of isolated iliac aneurysms

PURPOSE

This report describes our 5-year experience with the endovascular repair of isolated iliac aneurysms and pseudoaneurysms.

METHODS

Between June 1993 and July 1998, 40 isolated iliac aneurysms and pseudoaneurysms were treated with endovascular grafts in 39 patients. Thirty-seven aneurysms were treated with endovascular grafts composed of polytetrafluoroethylene grafts and balloon expandable stents, and the other three underwent repair with a polycarbonate urethane endoluminal graft.

RESULTS

All the patients underwent initially successful endovascular treatment of isolated iliac aneurysms and pseudoaneurysms and were followed from 1 to 51 months (mean, 18 months). The 4-year primary patency rate was 94.5% +/- 10%. The perioperative complications included one episode of distal embolization, an episode of colonic ischemia, five episodes of kinking or compression of the endovascular graft, and one early postoperative graft thrombosis. There was only one perioperative death in a patient whose aneurysm ruptured in the operating room just before endovascular repair. The median postoperative length of hospital stay was 3.0 +/- 1.3 days in this group of patients at moderate and high risk. The long-term complications included one graft thrombosis and two endoleaks. One small endoleak was followed until the patient died of unrelated causes, and the other one led to aneurysm rupture in the only patient temporarily lost to follow-up examination. This patient successfully underwent treatment in the standard open surgical fashion. To date, all the other aneurysms have remained stable or have decreased in size during the follow-up examinations with duplex or contrast-enhanced computed tomographic scans.

CONCLUSION

Endovascular repair of iliac aneurysms and pseudoaneurysms is a safe and effective technique with good midterm results in patients at standard and high risk. These grafts are particularly beneficial for patients with medical, surgical, or anatomic contraindications for open surgical repair.

Percutaneous endoluminal stent and stent-graft placement for the treatment of femoropopliteal aneurysms: early experience

PURPOSE

To determine the efficacy of percutaneous endoluminal stents and stent-grafts for the treatment of isolated femoropopliteal aneurysms.

METHODS

Seven men (age 51-69 years) with femoropopliteal occlusions (n = 6) related to aneurysms and a patent femoropopliteal aneurysm (n = 1) were treated percutaneously. In two patients uncovered Wallstents and in five patients polyester-covered nitinol stents were implanted. Assessment was performed with Doppler ultrasound and duplex ultrasonography 24 hr, 1, 3, 6, 12, and 24 months after the intervention. Additionally, intraarterial angiography was performed at 6 months.

RESULTS

Stent placement succeeded in all cases. No immediate adjunctive surgical treatment was necessary. Ankle-brachial index (ABI) improved from 0.29 +/- 0. 29 (SD) before to 0.78 +/- 0.23 (SD) 24 hr after the intervention. One patient was lost to follow-up. Stent-graft occlusion occurred in four patients: after 2 days (n = 1), 1 month (n = 2), and 3 months (n = 1). One of the patients, whose stent occluded at 1 month, underwent successful recanalization with local fibrinolysis therapy. Three of the seven, all with three-vessel run-off, demonstrated patency of the stent, which was assessed by duplex ultrasonography at 29, 31, and 34 months. Breaking of the stent struts or significant stent migration was not observed.

CONCLUSIONS

These results in a small number of patients warrant further investigation to evaluate the role of percutaneous stents in femoropopliteal aneurysms. Until further data of clinical studies are available, this method cannot be recommended, and it cannot replace surgical treatment.

Aortic bifurcation reconstruction: use of the Memotherm self-expanding nitinol stent for stenoses and occlusions

PURPOSE

To assess the technical success, initial clinical outcome, and intermediate follow-up of the Memotherm nitinol self-expanding stent in aortic bifurcation reconstruction.

METHODS

Thirty-three patients (13 male, 20 female), mean age 64 years, were treated, who had symptoms classified by the Surgical Vascular Society/International Society of Cardiovascular Surgery (SVS/ICVS) classification as grade 2 in 11 (33%), grade 3 in 19 (58%) and grade 4 in 3 (9%) patients. Lesions were classified according to severity and type. Indications for placement of a Memotherm nitinol self-expanding stent were failed angioplasty in 14 (42%), chronic occlusions in 12 (37%), and complex stenoses in seven (21%) patients.

RESULTS

Sixty-seven stents were technically successfully placed in 66 aorto-iliac segments in 33 patients, with one major complication. Initial clinical outcome was improvement in 25 (81%), no change in four (13%), and a worsening in two (6%) patients by Rutherford criteria. Mean early ankle/brachial pressure index (ABI) gain was 0. 27 for occlusions and 0.05 for stenoses. Clinical follow-up was obtained in all patients, with retrospective angiographic follow-up in 28 (85%) at a mean of 16 months (range 12-26 months). The decrease in ABI and the decrease in angiographic luminal diameter at follow-up was determined as the "late loss." The mean ABI late losses were -0.06, 0.00, and 0.09, and the mean angiographic late losses were 6.7%, 10% and 14% for occlusions, stenoses, and normal segments respectively. Primary clinical patency was 96%, primary angiographic patency was 89%, and secondary angiographic patency was 93%.

CONCLUSION

The high technical success of stent placement, the low complication rates for aortic bifurcation reconstruction using the Memotherm self-expanding stent, and high clinical and angiographic patency maintained at intermediate follow-up support their use in aortic bifurcation reconstruction.

Combined catheter embolization and femorofemoral bypass for pseudoaneurysm of the right external iliac artery: report of a case

Performing direct surgery for postoperative hemorrhage caused by intraperitoneal arterial injury is very difficult. We report herein the case of a 52-year-old woman who developed sudden right lower abdominal pain after numerous laparotomies and radiotherapy for advanced uterine cancer. A diagnosis of pseudoaneurysm of the right external iliac artery was made, and an emergency catheter embolization and femorofemoral bypass was successfully performed under local anesthesia. The patient was able to walk the next day. To the best of our knowledge, this is the first report of such a combined procedure in the literature.

Primary stenting for complex atherosclerotic plaques in aortic and iliac stenoses

PURPOSE

To evaluate the efficacy of primary stenting for complex atherosclerotic plaques in aortic and iliac stenoses that are not amenable to balloon angioplasty alone.

METHODS

Nineteen patients with complex atherosclerotic plaques were treated with a Palmaz stent (n = 19), Wallstent (n = 1), Strecker stent (n = 1), or Memotherm stent (n = 1). A total of 22 stenoses presenting with complex plaque morphology including ulcerated plaques, ulcerated plaques with focal aneurysms, plaques with heavy calcification, severely eccentric plaques, plaques with overhanging edge, and plaques with spontaneous dissection were stented. The lesions were in the aorta (n = 1), common iliac artery (n = 19), or external iliac artery (n = 2).

RESULTS

Immediate angiography after stent placement revealed restoration of patency of the stented segment. Focal aneurysms and ulcerated areas were occluded in the follow-up angiographies obtained 4-12 weeks after the procedure. In one case with poor distal runoff and multiple complex lesions of the iliac artery, subacute occlusion occurred. Clinical and angiographic follow-up (3-46 months) revealed patency of all other stented segments.

CONCLUSION

Primary stenting is an effective and reliable approach for complex plaques in stenoses. Patency of the arterial segment with a smooth lumen can be created without the risk of acute complications such as distal embolization, dissection, or occlusion.

Contemporary management of isolated iliac aneurysms

OBJECTIVE

Because isolated common iliac artery aneurysms are infrequent, are difficult to detect and treat, and have traditionally been associated with high operative mortality rates in reported series, we analyzed the outcomes of operative repair of 31 isolated common iliac artery aneurysms in 21 patients to ascertain morbidity and mortality rates with contemporary techniques of repair.

METHODS

A retrospective review study was conducted in a university teaching hospital and a Department of Veterans Affairs Medical Center. Perioperative mortality and operative morbidity rates were examined in 17 men and four women with isolated common iliac artery aneurysms between 1984 and 1997. Ages ranged from 38 to 87 years (mean 69 +/- 8 years). Slightly more than half of the cases were symptomatic, with abdominal pain, neurologic, claudicative, genitourinary, or hemodynamic symptoms. One aneurysm had ruptured and one was infected. There was one iliac artery-iliac vein fistula. All aneurysms involved the common iliac artery. Coexistent unilateral or bilateral external iliac aneurysms were present in four patients; there were three accompanying internal iliac aneurysms. Overall, 52% of patients had unilateral aneurysms and 48% had bilateral aneurysms. Aneurysms ranged in maximal diameter from 2.5 to 12 cm (mean 5.6 +/- 2 cm). No patients were unavailable for follow-up, which averaged 5.5 years.

RESULTS

Nineteen patients underwent direct operative repair of isolated iliac aneurysms. One patient had placement of an endoluminal covered stent graft; another patient at high risk had percutaneous placement of coils within the aneurysm to occlude it in conjunction with a femorofemoral bypass graft. Patients with bilateral aneurysms underwent aortoiliac or aortofemoral interposition grafts, whereas unilateral aneurysms were managed with local interposition grafts. There were no deaths in the perioperative period. Only one elective operation (5%) resulted in a significant complication, compartment syndrome requiring fasciotomy. The patient treated with the covered stent required femorofemoral bypass when the stent occluded 1 week after the operation. The patient treated with coil occlusion of a large common iliac aneurysm died 2 years later when the aneurysm ruptured.

CONCLUSIONS

Isolated iliac artery aneurysms can be managed with much lower mortality and morbidity rates than aneurysm previously been reported by using a systematic operative approach. Percutaneous techniques may be less durable and effective than direct surgical repair.

Intraluminal signal intensity of iliac artery stents investigated by contrast-enhanced three-dimensional MR angiography

The purpose of this study is to investigate the intraluminal signal of iliac artery stents by contrast-enhanced three-dimensional magnetic resonance (MR) angiography with a short echo time. Ten patients with iliac arterial diseases treated by intravascular metallic stent placement were examined with a 1.5 T MR imager. Gadolinium-enhanced MR angiography depicted the intraluminal signal in Strecker stent, but not in the Wallstent and Palmaz stent. Strecker stent made of nonferromagnetic tantalum was the best-suited stent for use with contrast-enhanced MR angiography.

Percutaneous endovascular stent-graft repair of iliac artery aneurysms

PURPOSE

To report a percutaneous technique for endovascular repair of iliac artery aneurysms using commercially available materials.

METHODS

Ten patients (9 males; mean age 65 +/- 11 years) presented with 11 isolated iliac artery aneurysms; 3 patients were asymptomatic. Stent-grafts were customized for each patient from polytetrafluoroethylene grafts with Palmaz stents sutured at either end of the tube. The devices were delivered percutaneously through standard 14F sheaths and deployed by balloon dilation.

RESULTS

All iliac aneurysms were excluded without procedural incident. One patient with chronic renal insufficiency (baseline serum creatinine 1.9 mg/dL) experienced transient contrast-induced renal failure inhospital. The average hospital stay was 2.5 days (range 1 to 7). One vessel thrombosed 2 weeks following the procedure; the culprit stenosis at the site of arterial cannulation was dilated. One patient died of myocardial infarction at 6 weeks. The remaining eight grafts are patent and free of endoleak at a mean 14-month follow-up.

CONCLUSIONS

This percutaneous technique appears to be an acceptable alternative to open surgical repair.

Case report: intravascular stenting across a false aneurysm of the popliteal artery

We present the case of a false aneurysm of the left popliteal artery in which the use of an uncovered metallic intravascular stent produced local aneurysmal thrombosis and maintained arterial blood flow to the distal lower limb. False aneurysms of the superficial femoral and popliteal arteries are uncommon but tend to occur at the adductor canal. We describe such a case and percutaneous management with a metallic stent (Strecker, Meditech, Boston Scientific).

Endovascular repair of residual iliac artery aneurysms following surgery for ruptured abdominal aortic aneurysm

Emergency repair of ruptured abdominal aortic aneurysm continues to have a high mortality. Such patients require expeditious operations to repair the ruptured segment rather than attempts to deal with all coexisting disease. The use of endovascular techniques obviates the need for open surgery to repair iliac aneurysms. We report two patients who, after successful repair of ruptured abdominal aortic aneurysms, had three iliac artery aneurysms treated successfully by embolisation in one case and percutaneous insertion of a self expandable stent graft in two cases. The issues that arise from such an approach are discussed with a review of the literature.

Successful exclusion of a large femoropopliteal aneurysm with a covered nitinol stent

A 70-year-old woman presented with a large femoro-popliteal aneurysm. A covered nitinol stent was implanted successfully and complete exclusion of the aneurysm was achieved. At follow-up 5 months later the stent was still patent and the patient was free of symptoms. However, moderate stenosis was seen at the proximal end of the stent.

Transfemoral endovascular repair of iliac artery aneurysms

PURPOSE

This report evaluates the application of transfemoral endovascular repair of iliac artery aneurysms.

PATIENTS AND METHODS

Over a 20-month period, 11 patients with serious comorbid illnesses and a total of 14 iliac artery aneurysms were treated with endovascular grafts composed of polytetrafluoroethylene conduits combined with balloon expandable iliac artery stents (Palmaz). Nine right common, 3 left common, and 2 right internal iliac artery aneurysms were treated. The patients were men between 58 and 89 years of age (mean 72). Eight patients had isolated aneurysms and 3 had multiple iliac artery aneurysms.

RESULTS

Endovascular iliac grafts were successfully placed in all 11 patients. No procedural deaths occurred. Follow-up ranged from 3 to 21 months (mean 11). No acute or late graft thromboses occurred.

CONCLUSIONS

Transluminally placed endovascular stented grafts can be used to successfully exclude iliac artery aneurysms from the circulation while maintaining lower-extremity arterial perfusion. However, longer follow-up in more patients is necessary to confirm the durability of this technique.