Balloon-expandable covered stent therapy of complex endovascular pathology

The current study was designed to investigate our hypotheses that balloon-expandable covered stents display acceptable function over longitudinal follow-up in patients with complex vascular pathology and provide a suitable alternative for the treatment of recurrent in-stent restenosis. All stents were Atrium iCast, which is a balloon-mounted, polytetrafluoroethylene-covered stent with a 6F/7F delivery system. A retrospective review was performed of 49 patients with 66 stented lesions. Data were analyzed with life tables and t-tests. The most commonly treated vessels were the iliac (61%) and renal (24%) arteries. Indications for covered stent placement were unstable atheromatous lesions (50%), recurrent in-stent restenosis (24%), aneurysm (8%), aortic bifurcation reconstruction (7.5%), dissection (4.5%), endovascular aneurysm repair-related (4.5%), and stent fracture (1.5%). Patency was assessed by angiogram or duplex ultrasonography. The primary end point was patency and secondary end points were technical success and access-site complications. Mean follow-up was 13 months (range 1.5-25). The technical success rate was 97%. Unsuccessful outcomes were due to deployment error (n=1) and stent malpositioning (n=1). The cohort (n=64) 6- and 12-month primary patency rates were 96% and 84%, respectively. Twelve-month assisted primary patency was 98%. Iliac artery stents (n=38) had a primary patency of 97% at 6 months and 84% at 12 months with an assisted primary patency of 100% at 12 months. Renal artery stents (n=16) had a primary patency of 92% at 6 months and 72% at 12 months with an assisted primary patency of 92% at 6 and 12 months. Stents placed for recurrent in-stent restenosis (n=16) had a primary patency of 85%, assisted primary patency of 93%, and a 15% restenosis rate at 12 months. Specifically, stents placed for renal artery recurrent in-stent restenosis (n=10) had a primary patency of 73%, assisted primary patency of 82%, and a restenosis rate of 27%. The restenosis rate included two renal artery occlusions in patients noncompliant with clopidogrel use and resulted in ipsilateral kidney loss in both patients. In-stent peak systolic velocities decreased significantly (p<0.05) from preoperation to 12 months in iliac stents and to 18 months in renal stents. Ankle-brachial index increased significantly in iliac stents from preoperation (0.62+/-0.18) to 18 months (0.86+/-0.16). Successful exclusion of atheromatous lesions and aneurysm/dissection/endoleak was 100%. Access-site complications occurred in 6%: pseudoaneurysm (n=2), dissection (n=1), and bleeding (n=1). Balloon-expandable covered stents have an acceptable primary patency with an excellent assisted patency after salvage angioplasty. The clinical utility of this technology is broad for the treatment of aneurysms, extravasation, unstable atheromatous lesions, and recurrent in-stent restenosis.     

Early results of stent-grafting to treat diffuse aortoiliac occlusive disease

INTRODUCTION: Diffuse aortoiliac occlusive disease or isolated external iliac artery occlusion >or=10 cm long typically are treated with surgical bypass grafting because of limited durability of stent placement. We evaluated the results of stent-graft placement as an option for treatment of these diseases. METHODS: Demographic data for patients undergoing stent-grafting in one or more iliac artery segments were recorded. Technical, clinical, and hemodynamic success, and aortoiliac primary and secondary patency were analyzed with Society for Vascular Surgery/American Association for Vascular Surgery criteria. RESULTS: Thirty-four consecutive patients underwent stent-graft treatment because of rest pain (65%) or tissue loss (35%). Mean patient age was 63 years, and 38% of patients were women. Ninety-one percent of patients had hypertension, 71% had coronary artery disease, 21% had renal insufficiency (serum creatinine > 2.0 mg/dL), and 26% had diabetes; 71% were active smokers. TransAtlantic Inter-Society Consensus C or D disease was present in 85% of patients, complete common or external iliac artery occlusion was present in 41%, and external iliac artery disease requiring treatment was present in 94% of patients. Mean lesion length was 13.7 +/- 8 cm. Technical, hemodynamic, and clinical success was achieved in all patients in whom the lesion could be crossed with a wire. Ankle-brachial index increased from.30 +/-.03 to.59 +/-.04. Self-expanding stent grafts were used (Wallgraft, Boston Scientific, Boston, Mass, in 88% of patients; Viabahn, W. L. Gore, Flagstaff, Ariz, in 12% of patients). Concomitant common femoral endarterectomy was performed in 53% of patients. At 12 months, primary patency was 70% and primary assisted patency was 88%. Four stent grafts became occluded because of distal external iliac artery or proximal common femoral artery disease, which required subsequent common femoral endarterectomy and either external iliac artery stent grafting or extraanatomic bypass grafting. Eighty percent (four of five) of primary patency failures were in patients who did not undergo concomitant common femoral endarterectomy at initial stent graft placement. CONCLUSION: Early results of stent-graft placement to treat diffuse aortoiliac occlusive disease appear better than our recent experience with stenting alone. Concomitant common femoral endarterectomy or better assessment of femoral disease may improve durability.     

Primary stent placement for iliac artery chronic total occlusions

Purpose

The purpose of this study was to evaluate the technical and mid-term results of primary stent placement for chronic total occlusions (CTO) of the iliac artery, in comparison to stent placement for iliac artery stenosis.

Methods

A retrospective study was carried out on 114 consecutive limbs with 24 CTOs and 90 stenoses of the iliac artery that underwent primary stent placement. Primary, assisted primary patency, and limb salvage rates were determined in accordance with the Society for Vascular Surgery guidelines.

Results

Angiographic and intravascular ultrasonographic success was achieved in all 114 limbs (100%). Three major complications, including 1 distal embolism and 2 arterial ruptures, occurred in the CTO group. The 2-year primary patency rate in the CTO group was as high as that observed in the stenosis group (91% vs 89%). There were also no significant differences in the assisted primary patency, limb salvage, and survival rates between the two groups.

Conclusions

Our results indicate that primary stent placement is a safe and effective treatment for iliac CTOs. However, major complications, including distal embolization and iliac artery rupture, remain a significant problem, and caution should therefore be exercised when performing this technique for iliac CTOs.     

Recanalization of totally occluded iliac and adjacent venous segments

PURPOSE: The purpose of this study was to report our experience with percutaneous recanalization of totally occluded iliac veins and inferior vena cava. Material and Methods: Recanalization of the iliac vein was performed in 38 limbs. In nine limbs, recanalization of the inferior vena cava was also necessary (two with filter). In 28 of 38 limbs, the stent was extended below the groin crease into the common femoral vein segment. Large-caliber (14 or 16 mm for iliac vein) flexible self-expanding stents were used. Stents were routinely extended for a short distance into the inferior vena cava to forestall development of iliocaval stenosis. Intravascular ultrasound scan was a valuable tool in the procedure. The median length of the recanalized segment was long (22 cm), and multiple stents (median, n = 3) were necessary in most patients. Forty-five percent of the patients had coagulation abnormalities. RESULTS: No morbidity or mortality was seen. Actuarial primary, primary assisted, and secondary patency rates of the stents at 24 months were 49%, 62%, and 76%, respectively. Median pain level decreased significantly (level 4 to level 0; P <.0001) after stent placement, and more than two thirds of the patients became totally pain free after the procedure. Swelling also improved significantly, and a third of the patients became totally free of any swelling after stent placement. Sixty-six percent of cases with stasis ulcers/dermatitis (n = 14) were resolved (actuarial, 1 year), although uncorrected reflux persisted in many of these limbs. CONCLUSION: Percutaneous recanalization of the occluded iliac vein with stent placement appears to be successful in the short term, with good patency, significant symptom resolution, and minimal morbidity.     

Double-barrel technique for preservation of aortic arch branches during thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) may involve either planned or inadvertent coverage of aortic branch vessels when stent grafts are implanted into the aortic arch. Vital branch vessels may be preserved by surgical debranching techniques or by placement of additional stents to maintain vessel patency. We report our experience with a double-barrel stent technique used to maintain aortic arch branch vessel patency during TEVAR. Seven patients underwent TEVAR using the double-barrel technique, with placement of branch stents into the innominate (n = 3), left common carotid (n = 3), and left subclavian (n = 1) arteries alongside an aortic stent graft. Gore TAG endografts were used in all cases, and either self-expanding stents (n = 6) or balloon-expandable (n = 1) stents were utilized to maintain patency of the arch branch vessels. In three cases the double-barrel stent technique was used to restore patency of an inadvertently covered left common carotid artery. Four planned cases involved endograft deployment proximally into the ascending aorta with placement of an innominate artery stent (n = 3) and coverage of the left subclavian artery with placement of a subclavian artery stent (n = 1). TEVAR using a double-barrel stent was technically successful with maintenance of branch vessel patency and absence of type I endoleak in all seven cases. One case of zone 0 endograft placement with an innominate stent was complicated by a left hemispheric stroke that was attributed to a technical problem with the carotid-carotid bypass. On follow-up of 2-18 months, all double-barrel branch stents and aortic endografts remained patent without endoleak, migration, or loss of device integrity. The double-barrel stent technique maintains aortic branch patency and provides additional stent-graft fixation length during TEVAR to treat aneurysms involving the aortic arch. Moreover, the technique uses commercially available devices and permits complete aortic arch coverage (zone 0) without a sternotomy. Although initial outcomes are encouraging, long-term durability remains unknown.     

Endovascular treatment of the descending thoracic aorta.

OBJECTIVES: to report our initial experience with endovascular stent graft repair of a variety of thoracic aortic pathology. DESIGN: retrospective single center study. MATERIAL AND METHODS: between February 2000 and January 2002, endovascular stent graft repair was performed in 26 patients: traumatic aortic isthmus rupture (n=3), Type B dissection (n=11) and descending thoracic aortic aneurysm (n=12). The deployed stent graft systems were AneuRx-Medtronic (n=1), Talent-Medtronic (n=13) and Excluder-Gore (n=12). RESULTS: successful deployment of the stent grafts in the intended position was achieved in all patients. No hospital mortality neither paraplegia were observed. Late, non procedure related, death occurred in four patients (15%). Access artery complications with rupture of the iliac artery occurred in two patients and were managed by iliac-femoral bypass. The left subclavian artery was overstented in seven patients (27%). Only the first patient received a carotido-subclavian bypass. The mean maximal aortic diameter decreased significantly in patients treated for descending thoracic aneurysm. Only one patient had an endoleak type II after 6 months without enlargement of the aneurysm. Complete thrombosis of the thoracic false lumen occurred in all but one patient treated for Type B dissection 6 months postoperatively. Two patients underwent a consecutive stent graft placement, due to a large re-entry tear distal to the first stent graft. CONCLUSIONS: endovascular stent graft repair for Type B dissection, descending thoracic aneurysm and aortic isthmus rupture is a promising less-invasive alternative to surgical repair. Further studies are mandatory to determine its long-term efficacy.     

Predictors for adverse outcome after iliac angioplasty and stenting for limb-threatening ischemia

OBJECTIVE: The role of iliac artery angioplasty and stenting (IAS) for the treatment of limb-threatening ischemia is not defined. IAS has been used primarily for patients with disabling claudication. Because poorer results have been shown in patients with critical ischemia after iliac artery angioplasty, the purpose of this study was to estimate the influence of risk factors on the outcome of iliac angioplasty and stent placement in patients with limb-threatening ischemia. METHODS: During a 5-year period (from 1996 to 2001), 85 iliac angioplasty and stent placement procedures (107 stents) were performed in 31 women and 43 men with limb-threatening ischemia. Patients with claudication were specifically excluded. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery) were followed to define the variables. The TransAtlantic InterSociety Consensus classification was used to characterize the type of iliac lesions. Both univariate (Kaplan-Meier [KM]) and multivariate analyses (Cox proportional hazards model) were used to determine the association between variables, cumulative patency, limb salvage, and survival. RESULTS: Indications for iliac angioplasty with stenting were ischemic rest pain (56%) and tissue loss (44%). Primary stenting was performed in 36 patients (42%). Stents were placed selectively after iliac angioplasty mainly for residual stenosis or pressure gradient (43%). Overall, primary stent patency rate was 90% at 1 year, 74% at 3 years, and 69% at 5 years. Primary stent patency rate was significantly reduced in women compared with men (KM, log-rank test, P <.001). Primary patency rates at 1, 3, and 5 years were 79%, 57%, and 38% for women and 92%, 88%, and 88% for men. Primary stent patency rate also was significantly reduced in patients with renal insufficiency (creatinine level, >1.6 mg/dL; KM, log-rank test, P <.001). Cox regression analysis identified female gender (relative risk, 5.1; 95% CI, 1.8 to 7.9; P =.002) and renal insufficiency (relative risk, 6.6; 95% CI, 1.6 to 14.2; P =.01) as independent predictors of decreased primary stent patency. No independent predictors for limb salvage and survival were identified. CONCLUSION: Women undergoing iliac angioplasty and stenting for limb-threatening ischemia have significantly reduced primary stent patency rates and may need additional procedures to obtain satisfactory clinical improvement and limb salvage. Patients with renal insufficiency and critical ischemia also have reduced primary stent patency rates after IAS. Limb salvage, as shown in this study, is not affected by previous iliac stent failure.     

Intraoperative Kombinationsverfahren bei pAVK vom Beckentyp

Background

Our aim was to compare intraoperative combined versus traditional surgical procedures at the aorto-iliac level during long-term follow-up.

Methods

From 1991 to 1999 a total of 42 aortic or iliac stents were placed in 34 patients. In 76.4%, there was a high preoperative risk (ASA-score III and IV). Stent placement was performed only in iliac TASC type A stenosis and combined with femoral patchplasty (n=10), ipsilateral (n=2) and cross-over bypass (n=22).

Results

The technical success of stent placement was 100%. Two cases of stent associated stenosis were treated successfully with PTA, bypass occlusion in five patients with successful thrombectomy in two cases. A single perioperative death (2.9%) occurred. In one patient, major amputation was necessary. The primary (secondary) patency rate after 1, 2, 5 and 7 years was 85%, 81%, 81% and 81% (91%, 85%, 85% und 85%).

Conclusions

Intraoperative combined procedures had a patency rate comparable to traditional aorto-iliac reconstructions while showing lower morbidity and mortality. The endovascular procedure can be performed safely and successfully by vascular surgeons.     

Early results of external iliac artery stenting combined with common femoral artery endarterectomy

PURPOSE: The endovascular approach to external iliac artery (EIA) disease extending into the common femoral artery (CFA) has been avoided because of problems with stent placement across the inguinal ligament. Surgical treatment for this disease distribution includes extensive endarterectomy or bypass procedures or both. We report our initial experience with a combined open and endovascular approach to these patients. METHODS: We performed a retrospective analysis of all patients who underwent intraoperative EIA stenting after CFA endarterectomy/patch angioplasty between 1997 and 2000. Stents were positioned to end at the proximal endarterectomy endpoint, without crossing the inguinal ligament. Technical success, hemodynamic success, and clinical success were determined according to Society of Vascular Surgery/International Society of Cardiovascular Surgery criteria. Life-table analysis was performed for patency. RESULTS: Thirty-four patients (mean age, 68 years; 23 male, 11 female) had combined endovascular and open treatment of iliofemoral occlusive disease. Indications were claudication in 41% and critical limb ischemia in 59%. Femoral reconstruction included endarterectomy with patch angioplasty in all patients. EIA stent deployment incorporated the stenotic iliac segment and the proximal endpoint of the endarterectomy in all patients. Four patients (12%) also needed common iliac angioplasty at the same time for proximal iliac disease, and 14 patients (41%) also needed distal revascularization for associated femoropopliteal or tibial disease. Technical success and hemodynamic success were achieved in 100% of patients. Clinical success was achieved in 97% of patients. The mean postoperative increase in ankle-brachial index in patients with inflow procedures only was 0.36 (range, 0.1 to 0.85). The overall complication rate was 15%. With a mean follow-up period of 13 months (range, 0.5 to 28 months), 1-year primary patency and primary-assisted patency rates were 84% and 97%, respectively. No perioperative mortality was seen. CONCLUSION: EIA stenting as an adjunct to CFA endarterectomy/patch angioplasty allows for more localized surgery than conventional bypass. This approach also allows a better interface between the stent and endarterectomy than staged preoperative stenting. Technical success and early patency rates are excellent.     

Adjunctive primary stenting of Zenith endograft limbs during endovascular abdominal aortic aneurysm repair: implications for limb patency

OBJECTIVE: Endograft limb occlusion is an infrequent but serious complication of endovascular abdominal aortic aneurysm (AAA) repair. The insertion of additional stents within the endograft limb may prevent future occlusion. This study evaluates limb patency with and without adjunctive stenting of endograft limbs at the time of endovascular AAA repair. METHODS: We performed a retrospective review of 248 patients who underwent endovascular abdominal aortic aneurysm repair with the Zenith AAA endovascular graft between 1999 and 2004. Among these patients, two groups were identified: 64 patients with adjunctive stents placed in 85 limbs and 184 patients without additional bare stent placement in endograft limbs at the time of endovascular AAA repair. RESULTS: Women comprised 23% of stented and 11% of unstented patients (P = .02). The mean length of follow-up in the stented and unstented groups was 2.0 years. There were 13 instances of limb thrombosis in 13 patients (5.2% of patients, 2.7% of limbs), all in the unstented group. No limb occlusions occurred in the presence of adjunctive bare metal stents. Seventy-three percent of the occlusions occurred < or = 6 months of endovascular AAA repair. Two patients (15%) had no symptoms of lower-extremity ischemia despite graft limb occlusion and did not undergo intervention. The others underwent thrombectomy (n = 2), thrombectomy with bare stent placement (n = 3), femoral-femoral bypass (n = 4), thrombolysis (n = 1), and thrombolysis with bare stent placement (n = 1). Of the seven who underwent thrombectomy or thrombolysis, three had no additional stents placed at the secondary procedure, and two of these three went on to rethrombose. By life-table analysis, primary patency at 3 years in the stented and nonstented limbs was 100% +/- 0% and 94% +/- 3%, respectively (P = .05). CONCLUSIONS: The intraoperative insertion of additional bare metal stents appeared to eliminate the risk of thrombosis and was without complication. Of the 85 stented limbs in this series, not one occluded. The overall rate of limb thrombosis was low, with most limb occlusions occurring < or = 6 months of stent-graft insertion, and would probably have been even lower had we been able to identify all high-risk cases for prophylactic adjunctive stenting. Limb occlusion denotes an underlying problem with the graft, which if left untreated after thrombectomy or thrombolysis will lead to rethrombosis. Postoperative imaging was of little value in detecting impending limb occlusion. Based on these findings, we believe one should identify and stent any limbs that appear to be at risk for thrombosis, but this study lacks the data to predict which limbs need stenting.     

术中髂动脉支架结合股动脉旁路术治疗多节段动脉硬化闭塞症

目的 探讨术中髂动脉腔内成形及支架植入结合股-Guo动脉旁路术治疗多节段动脉硬化闭塞症的初步临床经验。方法 采用术中同时行髂动脉腔内成形和支架植入结合股-Guo动脉旁路术治疗多节段动脉硬化闭塞症10例（12条肢体）。结果 术中11条髂动脉行腔内成形和支架植入均获成功,9条肢体行股-Guo动脉人工血管旁路术,3条肢体行股-股-Guo动脉人工血管旁路系列转流术;1条肢体股-Guo动脉旁路术失败,本组患者无重要脏器并发症和手术死亡。平均随访时间6个月（1-12个月,髂动脉腔内支架通畅率100%;3条股-股动脉耻骨上人工血管转流均通畅;而股-Guo动脉人工血管通畅率83.3%;截肢率8.3%。结论 术中髂动脉腔内支架结合股-Guo动脉旁路术是治疗多节段动脉硬化闭塞症的安全、有效方法。     

Neoaortic Reconstruction for Aortic Graft Infection: Need for Endovascular Adjunctive Therapies?

Neoaortic reconstruction using an autogenous conduit is an increasingly accepted option for the management of aortic graft infections. However, this approach is not without technical challenges and potential graft-related problems, some of which can be solved with endovascular techniques. All patients who underwent neoaortic reconstruction with femoral-popliteal vein for aortic graft infection over a 6-year period were identified from the operative registry. Those patients requiring endovascular adjunctive therapies form the basis of this report. Of 17 cases of neoaortic reconstruction for aortic graft infection, five (29%) required endovascular adjunctive procedures. These included stent placement for graft stenosis (n = 3), stent graft placement for proximal anastomotic stenosis (n = 1), and stent graft placement for anastomotic disruption (n = 1). While two of these procedures occurred within 30 days of the original neoaortic reconstruction, three were required during late follow-up. Although there were no direct complications related to the endovascular procedures, the patient with anastomotic disruption died within 30 days of causes unrelated to the endovascular procedure. Primary patency of neoaortic reconstruction was 87% at 30 days and 61% at 3 years, with assisted primary patency increasing to 100% at 3 years after endovascular adjunctive intervention. While neoaortic reconstruction using an autogenous conduit for aortic graft infection has proven durability, it is not without potential early and late graft complications. When graft problems occur, endovascular options are an attractive alternative to reoperative open aortic procedures, especially in the setting of a vastly altered surgical field. Presented at the Fifteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, January 28-30, 2005.     

The clinical impact of iliac venous stents in the management of chronic venous insufficiency.

PURPOSE: The purpose of this study was the presentation of the results of iliac venous stent placement in the management of chronic venous insufficiency (CVI). METHODS: Balloon dilation and stent placement for the relief of iliac vein stenoses was performed in 304 limbs with symptomatic CVI. Sixty-one limbs had concomitant saphenous vein ablation. The median age was 52 years (range, 14 to 83 years). The ratio of postthrombotic to nonthrombotic CVI was 1 to 0.9. The CEAP classification clinical scores were: C(2), 24; C(3), 158; C(4), 60; C(5), 13; and C(6), 49. Associated reflux was present in 57% of the limbs. The procedure was performed on an outpatient basis. Intravascular ultrasound scanning was routinely performed because transfemoral venography had poor sensitivity for the detection of iliac vein stenosis. RESULTS: The actuarial primary and secondary stent patency rates at 24 months were 71% and 90%, respectively. The median degree of swelling (graded 0 to 3, for none, pitting, ankle edema, to gross leg edema) declined from grade 2 to grade 1 after surgery (P <.001). The limbs without any swelling increased from 12% before stenting to 47% after stenting (P <.01). The pain level recorded on a visual analogue scale from 0 to 10 declined from a median level of 4 to 0 after stent placement (P <.001). The limbs that were completely free of pain increased from 17% before stenting to 71% after stent placement (P <.001). Stasis dermatitis/ulceration was present in 69 limbs. The improvement in swelling and pain was similar in ulcerated and nonulcerated limbs. The cumulative recurrence-free ulcer healing rate was 62% at 24 months. The rate of ulcer healing was similar whether or not concomitant saphenous ablation was performed. Quality of life has significantly improved. CONCLUSION: The correction of iliac vein outflow obstruction with the placement of stents results in the significant relief of major symptoms of CVI. The procedure is minimally invasive, can be performed on an outpatient basis, has minimal complications with a high patency rate, and does not preclude subsequent open surgery for the correction of restenosis or the associated reflux. If these preliminary results are sustained for a long-term period, stent placement for the correction of iliac vein stenoses may represent a useful advance in the management of CVI.     

The midterm results of stent graft treatment of thoracic aortic injuries

INTRODUCTION AND OBJECTIVES: Several publications document the technical feasibility of stent graft repair of aortic transection. We report our mid-term results of endovascular repair of thoracic aortic transections using covered stent grafts and compare this to a cohort undergoing open repair during the same time period to demonstrate the shift in practice pattern at our institution. MATERIALS AND METHODS: A retrospective review of patients who sustained blunt thoracic transection was undertaken. Medical records were examined to identify the clinical outcome of the procedure, and follow-up CT scans were reviewed to document adequate treatment of the transection. Outcome measures include procedure-related mortality, neurological morbidity, and successful immediate and mid-term coverage of the thoracic false aneurysm and absence of graft migration or endoleak. RESULTS: From July, 2000 to October, 2004, 27 patients were identified with descending thoracic aortic transection at our level I trauma center. Fourteen patients were managed nonoperatively, five patients underwent thoracotomy and direct aortic repair, and eight patients underwent endoluminal stent graft repair. Of the endovascular group (n=8), repairs were performed with stacked AneuRx aortic cuffs (Medtronic, Inc., Minneapolis, MN) (n = 6), a Gore thoracic aortic stent graft (Thoracic EXCLUDER; W.L. Gore, Flagstaff, AZ) (n=1), or a Medtronic Talent thoracic endograft (Medtronic, Inc.) (n=1). Access for stent graft deployment was the common femoral artery (n=2), iliac artery (n=4), or distal abdominal aorta (n=2). Completion arch aortography and postoperative CT scanning confirmed successful management of the aortic transection in each patient. There were no procedure-related deaths, paraplegia, or stroke. Postoperative complications included a brachial artery thrombosis in one patient as well as an external iliac artery dissection and acute renal failure in a second patient for a complication rate of 37.5%. Two patients died as a result of their injuries unrelated to the stent graft repair. Mean follow-up of 16.6 mo has shown no evidence of endoleak or stent graft migration. Of the open repair group (n=5), one patient died in the operating room during attempted aortic repair, and one patient had a postoperative stroke. CONCLUSIONS: Due to technical success and absence of delayed complications including endoleak and graft migration, stent graft repair of traumatic aortic transection has replaced open aortic repair as the primary treatment modality in the multiply injured trauma patient at our institution. The postoperative complication rate observed in this small series tempers the success to some degree, but the severity of the complications compares favorably with those observed in the open repair group.     

Iliac artery stenting in patients with poor distal runoff: Influence of concomitant infrainguinal arterial reconstruction

OBJECTIVE: Inadequate infrainguinal runoff is considered an important risk factor for iliac stent failure. However, the influence of concomitant infrainguinal arterial reconstruction (CIAR) on iliac stent patency is unknown. This study evaluated the influence of CIAR on outcome of iliac angioplasty and stenting (IAS) in patients with poor distal runoff. METHODS: Over 5 years (1996 to 2001), 68 IAS procedures (78 stents) were performed in 62 patients with poor distal runoff (angiographic runoff score >or=5). The SVS/AAVS reporting standards were followed to define outcome variables and risk factors. Data were analyzed with both univariate analysis (Kaplan-Meier method [K-M]) and regression analysis (Cox proportional hazards model). RESULTS: Indications for iliac artery stenting were disabling claudication (59%) and limb salvage (41%). Of the 68 procedures, IAS with CIAR was performed in 31 patients (46%), and IAS alone was performed in 37 patients (54%). Patients undergoing IAS with CIAR were older (P =.03) and had more extensive and multifocal iliac artery occlusive disease, with more TASC (TransAtlantic Inter-Society Consensus) type C lesions (P =.03), compared with patients undergoing IAS alone. No other significant differences in risk factors were noted. Runoff scores between patients undergoing IAS with CIAR and those undergoing IAS alone were not significantly different (median runoff scores, 6 [range, 5-8] and 7 [range, 5-9], respectively; P =.77). Primary stent patency rate at 1, 3, and 5 years was 87%, 54%, and 42%, respectively, for patients undergoing IAS with CIAR, and was 76%, 66%, and 55%, respectively, for patients undergoing IAS. Univariate analysis revealed that primary stent patency rate was not significantly different between the 2 groups (K-M, log-rank test, P =.81). Primary graft patency rate for CIAR was 81%, 52%, and 46% at 1, 3, and 5 years, respectively. Performing CIAR did not affect primary iliac stent patency (relative risk, 1.1; 95% confidence interval, 0.49-2.47; P =.81). Overall, there was a trend toward improved limb salvage in patients undergoing IAS with CIAR, compared with those undergoing IAS alone (K-M, log rank test, P =.07). CONCLUSION: In patients undergoing IAS with poor distal runoff, CIAR does not improve iliac artery stent patency. Infrainguinal bypass procedures should therefore be reserved for patients who do not demonstrate clinical improvement and possibly for those with limb-threatening ischemia.     

Fenestrated/branched endovascular aortic repair using unilateral femoral access in patients with iliac occlusive disease

ObjectiveFenestrated/branched endovascular aortic repair (F/BEVAR) in patients with occluded iliac arteries is challenging owing to limited access for branch vessel catheterization and increased risk for leg and spinal ischemic complications. The aim of this study was to analyze technical strategies and outcomes of F/BEVAR in patients with unilateral iliofemoral occlusive disease.MethodsWe performed a retrospective review of all consecutive patients treated by F/BEVAR in two institutions (2003-2021). Patients with unilateral iliofemoral occlusive disease were included in the analysis. All patients had one patent iliac artery that was used for advancement of the fenestrated-branch component. Preloaded catheter/guidewire systems or steerable sheaths were used as adjuncts to facilitate catheterization. Primary endpoints were technical success, mortality, major adverse events (stroke, spinal cord injury, dialysis or decrease in the glomerular filtration rate of more than 50%, bowel ischemia, myocardial infarction, or respiratory failure), primary iliac patency, and freedom from reinterventions.ResultsThere were 959 patients treated with F/BEVAR. Of these, 15 patients (1.56%; mean age, 74 years; 80% male) had occluded iliac arteries and 1 patent iliofemoral access and were treated for a thoracoabdominal aortic aneurysm (n = 8) or juxtarenal abdominal aortic aneurysm (n = 7). Brachial access was used in 14 of the 15 patients and preloaded systems in 7 of the 15 patients (47%). The remaining 53% had staggered deployment of stent grafts. There were seven physician-modified endovascular grafts, seven custom-made devices, and one off-the-shelf device used. Thirteen patients (87%) had distal seal using aortouni-iliac stent grafts and two (13%) had distal seal in the infrarenal aorta. Concomitant femoral crossover bypass (FCB) was performed in two patients and six patients had a prior FCB. Technical success was 100%. There were no intraoperative complications or early lower extremity ischemic complications, and all FCB were preserved. There was one mortality (7%) within 30 days owing to retrograde type A dissection. Major adverse events occurred in 20% of patients. The median follow-up was 12 months (range, 0-85 months). Two patients (13%) required three reinterventions. One patient required proximal stent graft extension for an acute type B dissection (3 months) and another required iliac extension for type Ib endoleak of an aortouni-iliac graft (21 months) and thrombolysis of that extension (50 months). At last follow-up, all patients had primary graft patency except one with secondary graft patency without new claudication. One patient had a single renal artery stent occlusion at follow-up with no r-intervention. The overall survival rate was 60%, without aortic-related deaths.ConclusionsAlthough challenging, F/BEVAR with unilateral femoral/brachial approach is feasible in patients with occluded iliac limbs, with an important rate of ischemic complications, but satisfactory outcomes.     

Endovascular Treatment of Isolated Iliac Artery Aneurysms

We report our experience of endovascular repair of isolated iliac artery aneurysms using commercially available stent grafts (SGs). Twenty-five patients (mean age 71 ± 7 years) presented with 33 isolated iliac artery aneurysms (common iliac artery n = 29, external iliac artery n = 4). Five patients were symptomatic. Depending on the proximal iliac neck and the presence of unilateral or bilateral iliac artery aneurysms, the patient was treated by tube or bifurcated SG that was delivered percutaneously (n = 14) or through surgical exposure of one femoral artery (n = 12). In our follow-up control protocol, the patients are routinely scheduled after 1, 4, and 12 months and then annually after the intervention. Primary technical success with an instant exclusion of the aneurysm was achieved in all patients. The perioperative (<30 days) mortality rate was 0. Major complications did not occur. Mean hospitalization was 6 ± 6 days (range 2-28, median 4). Four patients (16%) died during follow-up. At a mean follow-up of 32 months (range 3-72, median 36), we detected three type 1 endoleaks (14.3%) that were managed with additional SG; two stenoses at the distal extremity of the SGs, treated with mechanical thrombectomy; and additional stent. In the remaining patients (n = 17), computed tomography angiography confirmed the patency of the SG and the absence of device complication (e.g., endoleak, migration, breakage); shrinkage of the aneurysm was observed in 11 cases (52.4%). Overall, survival rates at 1, 4, and 5 years were 91.6%, 73.3%, and 58.6%, respectively; event-free rates at 1 and 3 years were 79.4% and 67.4%, respectively. In our experience, SG treatment for isolated iliac artery aneurysm proved to be a feasible and low-risk procedure with acceptable mid-term results. At our institute, it is the primary alternative to conventional surgical repair and is offered as first-line treatment.     

Long-term Results of Percutaneous Transluminal Angioplasty for Symptomatic Iliac In-stent Stenosis

OBJECTIVE: This study describes the long-term results of endoluminal therapy for iliac in-stent obstructions. DESIGN: This is a retrospective study. MATERIALS AND METHODS: From 1992 to 2005, 68 patients (22 women), with a mean age of 61+/- 13 years and 16 bi-iliac in-stent obstructions, underwent 84 endovascular interventions for focal iliac in-stent stenoses (n = 61) or occlusions (n = 23). Primarily, only uncovered stents were placed. All patients were symptomatic: 70% had disabling intermittent claudication, 23% had resting pain, and 7% had trophic changes. All had in-stent diameter reduction exceeding 50% that was confirmed by duplex scanning and angiography. Procedures were performed under local anesthesia via the femoral route. RESULTS: All interventions were initially technically successful, with a minor complication of pneumonia in one patient (2%). Initial clinical success was achieved in 86% of patients. PTA alone was used to treat 72 (86%) in-stent obstructions, the other 12 (14%) had PTA and renewed stent placement. The 30-day mortality rate was 0%. Mean follow-up was 35 months (range, 3 months to 10 years) and included duplex scanning. Primary clinical patency was 88% at 1 year, 62% at 3 years, and 38% at 5 years follow-up. During follow-up, 28 (33%) of 84 extremities required secondary reinterventions because of symptomatic renewed in-stent stenosis, and 11 were treated successfully with repeated endovascular interventions. Secondary patency at 1 year was 94%, 78% at 3 years, and 63% at 5 years. Surgical intervention was eventually needed in 17 (20%) of the 84 extremities. CONCLUSIONS: Endoluminal therapy for iliac focal in-stent obstructive disease seems to be a safe technique with acceptable long-term outcome and therefore a true alternative to primary surgical reconstruction.     

Complications of iliac artery stent deployment

Purpose: This study was performed to determine the primary patency, foot salvage, and complication rates associated with iliac artery stent deployment.Methods: From March 1992 to May 1995, 147 iliac artery stents were deployed in 98 limbs of 72 patients for disabling claudication or limb-threatening ischemia. Procedure-related and late (>30 days) complications, as well as adjunctive maneuvers required to correct a complication, were tabulated. Stented iliac artery cumulative primary patency and foot salvage rates were calculated with life-table analysis. Factors that impacted early complications, late complications, foot salvage rates, and stented iliac artery primary patency rates were identified with stepwise logistic regression analysis.Results: A procedure-related complication occurred in 19 (19.4%) limbs. Initial technical success, however, was achieved in all but three of 98 limbs (96.9%). Stented iliac artery cumulative primary patency rates were 87.6%, 61.9%, 55.3%, and foot salvage rates were 97.7%, 85.1%, 76.1%, at 12, 18, and 24 months, respectively. External iliac artery stent deployment, superficial femoral artery occlusion before treatment, and single-vessel tibial runoff before treatment negatively affected stented iliac artery cumulative primary patency rates. Stented iliac artery primary patency rates were not significantly affected by age, smoking, coronary artery disease, diabetes, hypercholesterolemia, hypertension, presenting symptom, early complication, number of stents deployed, type of stent deployed, or stent deployment for stenosis versus occlusion.Conclusions: Limb-threatening and life-threatening complications can be associated with iliac artery stent deployment. Stented iliac artery primary patency rates are affected by distal atherosclerotic occlusive disease and the position of the deployed stent within the iliac system. Stent reconstruction of severe iliac artery occlusive disease is feasible but should be thoughtfully selected. (J Vasc Surg 1996;24:545-55.)     

The importance of iliac fixation in prevention of stent graft migration

OBJECTIVE: Secure proximal fixation of endografts to the infrarenal aortic neck is known to be important in the short- and long-term success of endovascular aneurysm repair. We sought to determine the relative importance of distal iliac fixation in preventing endograft migration and adverse clinical events after endovascular aneurysm repair. METHODS: We reviewed the outcome of 173 patients treated from 1996 to 2003 at Stanford University Medical Center with an externally supported stent graft. Quantitative image analysis of the postimplantation computed tomography scan was performed to determine the proximal aortic and distal iliac fixation lengths and the proximity the distal end of the stent graft to the iliac bifurcation. Subsequent follow-up computed tomography scans were reviewed for evidence of stent graft migration. Patients were grouped according to good (>15 mm), intermediate, or bad (<10 mm) aortic fixation and good (iliac fixation length > or =25 mm and iliac limbs <10 mm from iliac bifurcation), intermediate, or bad (<25-mm fixation length) iliac fixation. RESULTS: Stent graft migration of 10 mm or more was seen in 17 patients (10%) during the 23 +/- 19-month follow-up period. Patients with no migration had a greater iliac fixation length (30 +/- 12 mm) than those with migration (22 +/- 8 mm; P = .01), and the distal ends of the iliac limbs were closer to the iliac bifurcation (15 +/- 12 mm) than in patients with migration (25 +/- 10 mm; P < .001). Patients with no migration also had a greater proximal aortic fixation length (23 +/- 12 mm) than migration patients (13 +/- 7 mm; P = .001). There were no migrations among patients with good iliac fixation whether aortic fixation was good, intermediate, or bad (0/63; 0%). Among patients with bad/intermediate iliac and good aortic fixation, there were 5 (9%) of 58 patients had migrations. Patients with both bad/intermediate iliac and bad/intermediate aortic fixation had the highest migration rate (12/52; 23%). Cox proportional hazards regression modeling revealed that the significant factors predicting migration were poor proximity of the distal end of the iliac limbs to the iliac bifurcation (odds ratio 17.2; P = .01) and aortic fixation length (odds ratio 2.0; p = 0.007 for each centimeter). Iliac extender modules were placed in 9 patients with bad iliac fixation and migration, with no further migration during a mean follow-up of 12 months. Patients with good iliac and aortic fixation and no endoleak on the initial postprocedure computed tomography scan (n = 43) had no migrations, secondary procedures, or adverse clinical events over a 2-year follow-up period. CONCLUSIONS: Iliac fixation, along with proximal aortic fixation, is an important factor in preventing the migration of stent grafts that have longitudinal columnar support. Patients with good iliac fixation did not experience migration even in the presence of suboptimal proximal aortic fixation. Close proximity of the distal end of the stent graft to the iliac bifurcation seems to provide stability against migration.