Value of stent placement during percutaneous transluminal angioplasty of the iliac arteries

BACKGROUND: To determine the benefits of stents during percutaneous transluminal angioplasty (PTA) of the iliac arteries. Retrospective analysis of our 10-year surgical experience with iliac PTA from 1988-1997 permitted comparison of results during two consecutive periods: an initial period (1988-1992), during which stents were never used, followed by a second period (1992-1997), when stenting was performed on indication. METHODS: From January 1988 to October 1997, 287 iliac PTA procedures (158 common iliac arteries, 129 external iliac arteries) were performed on 250 patients. Thirty-seven patients had two iliac lesions that were treated simultaneously. Indications for PTA included stenosis (270 cases) and chronic occlusion (17 cases). Thirty-one patients (12.4%) underwent infra-inguinal bypass in addition to PTA owing to the existence of arterial lesions at two levels. Two consecutive patient groups were defined: Group I consisted of 75 patients who underwent 86 iliac PTA procedures between January 1988 and May 1992 without stent placement; Group II consisted of 175 patients who underwent 201 iliac PTA procedures between June 1992 and October 1997, when selective stenting was performed. A total of 55 stents (35 in the common iliac artery, 20 in the external iliac artery) were placed in Group II during PTA due to unsatisfactory immediate results (dissection, residual stenosis) or occlusion. RESULTS: There was no 30-day mortality. There were 15 immediate failures of PTA: 8 in Group I (10.7%) and 7 in Group II (4%). The cumulative initial success rate was 94%. Follow-up ranged from 3 months to 102 months (mean 37 months). The cumulative primary patency rate at 4 years was 62% (58% in Group I, 64% in Group II). The cumulative secondary patency rate at 4 years (including patients who subsequently underwent repeat angioplasty procedures) was 72% (68% in Group I, 74% in Group II). CONCLUSIONS: Stents were an effective means for treatment of initial failures of PTA in patients with iliac artery occlusive disease. However, there were no significant differences in the long term results between PTA alone and PTA with selective stent placement.     

Traitement des sténoses et des oblitérations iliaques par angioplastie transluminale

PurposePercutaneous transluminal angioplasty (PTA) has an established and valuable role in the treatment of iliac stenoses and occlusions. The use of stents may improve the results of PTA. The aim of this study is to report our surgical experience of iliac angioplasty over the past 5 years.Patients and methodsFrom January 1993 to October 1997, 201 iliac PTA were performed in 175 patients, at the level of the common iliac artery (n = 111 ) and external iliac artery (n = 90). In 26 cases, two iliac lesions were treated simultaneously. There were 188 stenoses and 13 chronic occlusions. During PTA, 55 stents were used, because of unsatisfactory results (dissection, residual stenosis) or in case of total occlusion, in the common iliac artery in 35 cases and in the external iliac artery in 20 cases. In 15 cases (8.6%), a femoro-popliteal bypass was associated to the iliac PTA, because of multilevel occlusive disease.ResultsThere were no early deaths. There were seven initial failures. The initial success rate was 96%. The clinical follow-up has been achieved in 163 patients, (range: 3 to 48 months, mean: 28 months). The primary patency rates were 84%, 79% and 63% respectively at 1, 2, and 4 years. The secondary patency rates were 87%, 85% and 73% respectively at 1, 2, and 4 years.ConclusionPTA is a good procedure for aortoiliac disease. Selective use of stents may improve early results of PTA; however, routine use of stents cannot be recommended.     

Does stent placement improve the results of ineffective or complicated iliac artery angioplasty?

Objective: This study was undertaken to determine the results and complications of stents placed for initially unsuccessful or complicated iliac percutaneous transluminal angioplasty (PTA), the effect of location (external iliac or common iliac) on outcome, and the influence of superficial femoral artery patency on benefit. Design: From 1992 through 1997, 350 patients underwent iliac artery PTA at the authors' institutions. Of this group, 88 patients (88 arteries) had one or more stents placed after PTA (140 stents in total) for residual stenosis or pressure gradient (63 patients), iliac dissection (12 patients), long-segment occlusion (10 patients), or recurrent stenosis (3 patients). Thirty patients required the placement of more than one stent. The indications for PTA in these 88 patients were claudication (48 patients) and limb-threatening ischemia (40 patients). Forty-seven patients had stents placed in the common iliac, 29 patients had stents placed in the external iliac, and 12 patients had stents placed in both. Seventy-one arteries (81%) were stenotic, and 17 (19%) were occluded before PTA. Sixty-six arteries were treated by interventional radiologists, 15 by a vascular surgeon, and 7 jointly. Main outcome measure: Criteria for success included (1) increase of at least one clinical category of chronic limb ischemia from baseline or satisfactory wound healing, (2) maintenance of an ankle/brachial index increase of more than 0.10 above the preprocedure index, and (3) residual angiographic stenosis less than 25% and, for patients with pressure gradient measurements, a residual gradient less than 10 mm Hg. Results: Stent placement was accomplished in all 88 patients with 16 (18%) major complications. Mean follow-up was 17 months (range, 3 to 48 months). By life-table analysis, success was 75% at 1 year, 62% at 2 years, and 57% at 3 years. No cardiovascular risk factor or independent variable was statistically significant in predicting success. There was no difference in success rates for common iliac or external iliac lesions. Superficial femoral artery patency did not correlate with outcome. Conclusions: Although stents can eliminate residual lesions and arterial dissection, these patients are likely to require adjuvant or subsequent procedures to attain clinical success. By controlling the PTA complication and treating the emergent problem, stents may allow for subsequent elective intervention. (J Vasc Surg 1998;28:104-14)     

Long-term outcomes and predictors of iliac angioplasty with selective stenting

OBJECTIVE: To review our 11-year experience of iliac angioplasty with selective stenting and to evaluate the safety, short- and long-term patency, clinical success rates, and predictive risk factors in patients with iliac artery occlusive disease. METHODS: From August 1993 to November 2004, 151 iliac lesions (149 stenoses, 2 occlusions) in 104 patients were treated by percutaneous transluminal angioplasty (PTA). The patients had chronic limb ischemia described as disabling claudication (the Society for Vascular Surgery clinical category 2 or 3) in 76 (50%), rest pain (category 4) in 38 (25%), and ulcer/gangrene (category 5) in 37 (25%). Forty-six limbs (30%) were treated with concomitant infrainguinal endovascular (36, 24%) or open procedures (10, 6%). Thirty-four limbs (23%) had one or more stents placed for primary PTA failure, including residual stenosis (> or =30%), mean pressure gradient (> or =5 mm Hg), or dissection (stent group); whereas, 117 limbs (77%) underwent PTA alone (PTA group). The affected arteries treated were 28 (19%) common iliac, 31 (20%) external iliac, and 92 (61%) both arteries. According to TransAtlantic Inter-Society Consensus (TASC) classification, 39 limbs (26%) were in type A, 71 (47%) in type B, 36 (24%) in type C, and 5 (3%) in type D. Reporting standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery were followed. RESULTS: There was no perioperative death. Total complication rate was 0.7% (one groin hematoma). The mean follow-up was 21 months (median, 10; range, 1 to 94 months). Only 9 (8%) of 117 of the PTA group had subsequent stent placement for recurrent stenosis. The iliac lesions were more severe and extensive in the stent group than those in the PTA group according to TASC classification (Mann-Whitney U test [M-W], P < .0001) and anatomic location (M-W, P = .0019). The technical success rate was 99%, and the initial clinical success rate was 99%. Overall, the cumulative primary patency rates at 1, 3, and 5 years were 76%, 59%, and 49% (Kaplan-Meier [K-M]). The cumulative assisted primary and secondary patency rates at 7 years were 98% and 99% (K-M). The mean number of subsequent iliac endovascular procedures was 1.4 per limb in patients with primary failure of iliac angioplasty/stenting. The continued clinical improvement rates at 1, 3, and 5 years were 81%, 67%, and 53% (K-M). The limb salvage rates at 7 year were 93% (K-M). Of 15 predictor variables studied in 151 iliac lesions, the significant independent predictors for adverse outcomes were smoking history (P = .0074), TASC type C/type D lesions (P = .0001), and stenotic ipsilateral superficial femoral artery (P = .0002) for the primary patency rates; chronic renal failure with hemodialysis (P = .014), ulcer/gangrene as an indication for PTA (P < .0001), and stenotic ipsilateral superficial femoral artery (P = .034) for the continued clinical improvement (K-M, log-rank test and Cox regression model). CONCLUSIONS: Although the primary patency rates were not high, the assisted primary and secondary patency rates were excellent without primary stenting. Overall, >70% of iliac lesions were treated successfully with PTA alone. The results of this study show that selective stenting offers satisfactory assisted primary and secondary long-term patency after iliac angioplasty. Patients with TASC type C/type D iliac lesions, a stenotic ipsilateral superficial femoral artery, ulcer/gangrene, smoking history, and chronic renal failure with hemodialysis should be followed carefully after endovascular iliac revascularization. These risk factors could be considered indications for primary stenting, although further studies are needed to confirm this.     

Percutaneous placement of stents in chronic iliac and aortic occlusive disease.

OBJECTIVES: to evaluate the long-term results of stenting in iliac and aortic occlusive disease and identify factors predicting clinical outcome. Design: retrospective study. MATERIALS AND METHODS: 82 patients (87 limbs) with stenoses (n =63) and occlusions (n =24) in the aortoiliac segment were treated with stents. 81 lesions involved the iliac arteries, 3 the infrarenal aorta and 3 the aortic bifurcation. Primary stenting was performed in 57 limbs (complex stenotic lesions and occlusions). Stents were placed following failed PTA in 30 limbs. Median follow-up was 13.2 months (1-66 months). RESULTS: technical success was 99% and clinical success 89%. Cumulative primary and secondary patency of stented iliac atherosclerotic lesions at 1 and 3 years was 75 and 61%, and 83 and 75% respectively. The factors predicting outcome of primary patency identified in Cox multivariate analysis were ankle-brachial index (ABI) prior stenting (p =0.03) and length of the lesion (p =0. 007). Major non-fatal complications occurred in 7.4% of the patients and there were no deaths attributed to the treatment. The 30-day mortality was 3.7%. CONCLUSION: stenting of complex aortoiliac stenoses and chronic occlusions is a safe and effective treatment modality. Long lesions and lower pre-procedure ABIs were found to negatively influence outcome.     

External iliac and common iliac artery angioplasty and stenting in men and women

OBJECTIVE: The effect of anatomic location of stent placement on the outcome of iliac artery angioplasty and stenting is not defined. Analyses of patency rates of external iliac artery (EIA) and common iliac artery (CIA) stents have provided conflicting results and have not considered men and women independently. The purpose of this study was to estimate the influence of the anatomic location of stenting on the outcome of iliac angioplasty and stent placement in both men and women. METHODS: From 1995 to 1999, 247 iliac angioplasty and stent placement procedures (303 stents) were performed in 67 women and 122 men, and all were included in a retrospective cohort study. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery) were followed. The TransAtlantic Inter-Society 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 among the variables, cumulative patency, limb salvage, and survival. RESULTS: Indications for iliac angioplasty with stenting were disabling claudication (65%), limb salvage (33%), and blue toe syndrome (2%). Primary stenting was performed in 103 procedures (42%). Stents were placed selectively after iliac angioplasty mainly for residual stenosis or pressure gradient (43%). Patients with EIA stents, as compared with those who had CIA stents, had more extensive lesions (TransAtlantic Inter-Society Consensus type C lesions), poorer runoff, smaller vessel size, and less frequency of hyperlipidemia (P <.05). Primary patency rates at 1, 3, and 5 years were 76%, 56%, and 56%, respectively, for patients with EIA stents and 92%, 85%, and 76%, respectively, for those with CIA stents. Although overall primary patency rates were significantly decreased in patients with EIA lesions (KM, log-rank test, P =.001), stratified analyses revealed that women with EIA stents had the poorest outcome, with 61%, 47%, and 23% primary patency rates at 1, 3, and 5 years, respectively, (KM, log-rank test, P <.001). Cox regression analysis identified EIA stenting (relative risk, 4.3; 95% CI, 2.3-7.9; P <.001) as an independent predictor of decreased primary patency in women but not in men. CONCLUSIONS: Women undergoing EIA angioplasty with stent placement have significantly reduced primary patency rates. Despite initial technical success, these patients are at increased risk of long-term failure and might require subsequent procedures to obtain clinical success. Conversely, men undergoing EIA stenting have a more favorable outcome than women.     

Long-term Results of Primary Stent Placement to Treat Infrarenal Aortic Stenosis

OBJECTIVE: To determine the safety and the long-term results of primary stent placement for localized distal aortic occlusive disease. DESIGN: Retrospective observational study. PATIENTS AND METHODS: From July 1998 to July 2005 17 patients (14 female and 3 men, mean age 57 years (39-80)) were treated for intermittent claudication. Five of these patients underwent additional endovascular treatment of focal iliac lesions. RESULTS: Technical success defined as residual stenosis of less than 50% or a trans-stenotic systolic pressure gradient <10% was achieved in 14 of 17 (82%) patients. Major complications included dissection at the puncture site in one patient and thrombosis of additional iliac stents in another patient. Both of these complications were successfully treated. During a mean follow-up of 27 months (range 1-86), four patients had recurrence of symptoms due to in-stent restenoses (n=2), femoral (n=1) or iliac occlusion (n=1), respectively. By Kaplan-Meier analysis, primary aortic hemodynamic patency was 83% at 3 years. Secondary aortic hemodynamic patency was 100%. The primary clinical patency was 68% at 3 years. CONCLUSION: Primary stent placement for distal aortic stenoses is an alternative to surgical treatment because of its high patency and relatively low complication rates.     

The durability of endovascular treatment of multisegment iliac occlusive disease

PURPOSE: The effectiveness of endovascular treatment of multisegment iliac occlusive disease (involving two or more common and/or external iliac arteries) was determined. METHODS: All patients who underwent angioplasty or stenting of at least two separate iliac artery segments were identified. Demographic data were recorded. Technical success, hemodynamic success, and aortoiliac primary and primary-assisted patency were analyzed by using the Society for Vascular Surgery and International Society for Cardiovascular Surgery (SVS/ISCVS) criteria. Multivariate, life table analysis was used as a means of determining outcome predictors. RESULTS: Eighty-seven patients underwent 207 iliac artery angioplasties and 115 iliac artery stents, which were performed in 210 iliac segments for disabling claudication in 60% of cases, for rest pain in 17% of cases, and for tissue loss in 23% of cases. Two iliac segments were treated in 64% of patients, three segments were treated in 28% of patients, and four segments were treated in 8% of patients. The complication rate was 11%. Initial hemodynamic success was achieved in 72% of cases. Clinical improvement occurred in 88% of patients. Subsequent endovascular reintervention was required in 29% of patients, whereas surgical inflow procedures were required in 14% of patients to maintain aortoiliac patency. The mean time from the primary intervention to the first reintervention was 10 +/- 3 months. At 6, 12, and 36 months after intervention, the primary patency rates of the aortoiliac segment were 76%, 61%, and 43%, respectively, and the primary assisted patency rates were 95%, 87%, and 72%, respectively. Only the presence of an external iliac artery stenosis adversely affected both primary and assisted-primary patency. At 6, 12, and 36 months, the aortoiliac primary patency rates in patients without the presence of an external iliac artery stenosis were 88%, 78%, and 69%, respectively, compared with 68%, 47%, and 18%, respectively, in patients with external iliac artery lesions (P <. 0001). CONCLUSION: Endovascular therapy for multisegment aortoiliac occlusive disease has acceptable patency rates; however, reintervention is often needed. The presence of external iliac artery disease is a significant predictor of poor outcome.     

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.     

The Influence of the Ipsilateral Superficial Femoral Artery on Iliac Angioplasty

Our objective was to evaluate the impact of the ipsilateral superficial femoral artery (SFA) on percutaneous transluminal angioplasty (PTA) of the iliac arteries. From 1993 to 2005, 183 iliac lesions (179 stenoses, 4 occlusions; 37 common, 35 external, and 111 both iliac arteries) in 127 patients with disabling claudication [94 (52%)], rest pain [43 (23%)], and ulcer/gangrene [46 (25%)] were treated by PTA. TransAtlantic Inter-Society Consensus (TASC) iliac lesion types were A in 48 limbs (26%), B in 92 (50%), C in 38 (21%), and D in 5 (3%). Stents were placed selectively for primary angioplasty failure [residual stenosis (>30%) or pressure gradient (>5 mm Hg)]. Seventy-seven limbs (42%) had patent SFAs (66 intact/<50% stenosis and 11 previously bypassed, pSFA group), 28 (15%) had stenotic SFAs (50-99%, sSFA group), 51 (28%) had occluded SFAs (oSFA group), and 27 (15%) had concomitant SFA angioplasty (aSFA group). The Society for Vascular Surgery and the International Society for Cardiovascular Surgery reporting standards were followed to define outcomes. There were no perioperative deaths. Total complication rate was 1.1% (2/183, groin hematomas). The mean follow-up was 20 months (range 1-115). One hundred twenty-five limbs (68%) had PTA alone for iliac lesions, and 58 (32%) had iliac stenting (a total of 91 stents). TASC iliac lesion types and the status of the ipsilateral profunda femoris artery were not significantly different among the four groups. Seventeen limbs (9%) had subsequent infrainguinal bypass: three in the pSFA, seven in the oSFA, four in the sSFA, and three in the aSFA groups (p = 0.19). The primary patency rate was significantly decreased in the sSFA group (29% at 3 years, Kaplan-Meier log-rank, p < 0.0001) compared with the other three groups; however, there were no significant differences among the pSFA, oSFA, and aSFA groups (67%, 67%, and 86% at 3 years, respectively; p = 0.92). The continued clinical improvement rates were significantly decreased in the sSFA group (36% at 3 years, p = 0.0043) compared with the other three groups; however, there was no significant difference between the pSFA, oSFA, and aSFA groups (81%, 84%, and 75% at 3 years, respectively; p = 0.088). The assisted primary and secondary patency and limb salvage rates were not significantly different among the four groups (p > 0.40). Stratified analysis in patients with TASC type B/type C, critical limb ischemia, or claudicants revealed similar results. The primary patency and continued clinical improvement were significantly decreased in patients with stenotic SFAs, suggesting that concomitant SFA angioplasty might improve iliac patency after iliac PTA for patients with stenotic SFAs. The presence of an occluded SFA did not adversely affect the outcomes of iliac PTA. During iliac PTA, a stenotic SFA should be considered for revascularization via endovascular means but an occluded SFA can be observed.     

Long-term outcomes and predictors of iliac angioplasty with selective stenting: is primary stenting necessary?

Percutaneous transluminal angioplasty (PTA) has become one of the initial treatment options in patients with iliac artery occlusive disease. Stents have been recommended to correct procedural complications and improve long-term patency. Many series advocate routine stent placement after an otherwise uncomplicated PTA (primary stenting) in an attempt to prevent recurrent disease. Currently, many physicians in the United States seem to use stents in the iliac artery more liberally, even on a routine basis. There is little evidence to support this practice, however. It is still unclear whether a stent should be inserted primarily or selectively. This article provides the data from an 11-year experience of angioplasty with selective stenting for iliac artery occlusive lesions and reviews the current literatures on the iliac artery stent placement.     

Role of percutaneous transluminal angioplasty in aorto-iliac reconstruction

Thirty-seven percutaneous transluminal angioplasties were performed in 31 patients with disabling claudication caused by a short stenosis in the iliac segment. This retrospective study showed an overall patency rate by life-table analysis of 93% with a follow-up period of 4 years and 4 months. There were 2 primary failures and 4 minor complications. Two limbs relapsed but were successfully treated with second PTA. These results indicate that PTA is the procedure of choice in treatment of short iliac artery lesions.     

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。     

Percutaneous treatment of acute iliac artery injury after intraaortic balloon counterpulsation

We report on a novel approach to correcting iliac artery occlusions caused by aortic counterpulsation. Two patients who had leg ischemia after retrieval of an intraaortic balloon pump underwent angiograms that showed occlusion of the right external iliac artery because of dissection (one case) or thrombosis (one case). Percutaneous self-expandable stents were implanted in the occluded vessels, and they fully restored normal iliac patency with no complications and satisfactory midterm follow-up results. We conclude that iliac artery occlusion induced by aortic counterpulsation can be safely treated by implanting self-expandable stents in cases of acute iatrogenic dissection. (J Vasc Surg 1996;24:279-83.)     

Remote iliac artery endarterectomy: seven-year results of a less invasive technique for iliac artery occlusive disease

OBJECTIVE: Remote endarterectomy of external and common iliac artery occlusions through a single, groin incision under fluoroscopic guidance is a relative unknown surgical procedure. This prospective single center cohort study describes this less invasive endovascular technique with the ring strip cutter and its early complications. The results at midterm follow-up are presented. PATIENTS AND METHODS: From April 1994 to July 2001, 49 remote-endarterectomies of the external or common iliac artery were performed in a retrograde manner from a single, groin incision in 48 patients (30 men, 31 procedures). The median age was 66 years (39 to 82 years). Indications for operation were as follows: severe claudication in 28 (57%), rest pain in 13 (27%), and gangrene in 8 (16%) procedures. Follow-up included clinical evaluation, ankle-brachial index, and duplex scanning at 6 weeks, 3 months, and yearly thereafter. RESULTS: Intraoperative technical success was achieved in 43 (88%) procedures. A retroperitoneal incision was necessary in three patients for an additional arteriotomy in the iliac artery and in three others for a bypass procedure. The mean follow-up was 20 months (2 to 77 months). Three-year cumulative primary patency rate by means of life table analysis was 60.2% +/- 12.0 (SE). During follow-up, percutaneous transluminal balloon angioplasty with and without stenting was performed in six and two patients, respectively, resulting in a 3-year primary-assisted patency rate of 85.7% +/- 9.56. Three-year secondary patency was 94.2% +/- 5.50. CONCLUSIONS: Remote endarterectomy in external and common iliac arterial occlusive disease is a feasible endovascular procedure with a low complication rate. The midterm primary-assisted patency rate is good.     

Duplex selection facilitates single point-of-service endovascular and surgical management of aortoiliac occlusive disease

We attempted to optimize management of aortoiliac occlusive disease by using duplex imaging to aid in selection of favorable lesions for percutaneous transluminal angioplasty (PTA)/stenting, by avoiding nontherapeutic arteriography, and by providing single point-of-service care in which endovascular and open surgical reconstruction were combined. One-hundred consecutive patients with symptomatic (91 claudication, 9 limb threat) inflow occlusive disease based on clinical examination and physiologic testing underwent physician-directed duplex scanning of the infrarenal aorta through the femoral bifurcation. Iliac lesions suited to endovascular intervention were defined as focal (length <5 CM), high-grade stenoses with a peak velocity >300 cm/sec and velocity ratio >2 by duplex and were differentiated from unfavorable (diffuse/long iliac stenosis, occlusions, aneurysms, femoral occlusive disease) inflow lesions. Patients with favorable iliac lesions according to duplex were considered candidates for PTA/stenting in an endo-capable operating room, without prior diagnostic angiography. On the basis of duplex imaging, 38 patients possessed endovascularly favorable iliac lesions, 58 patients had unfavorable aortoiliofemoral disease, and 4 obese patients had inadequate studies. Duplex interpretation correctly classified disease distribution/severity in 92% of 50 patients who subsequently underwent intraoperative or diagnostic arteriography. Thirty-one of the 45 (69%) total interventions performed in this patient group were based on duplex findings alone. Of 29 patients with favorable lesions by duplex scanning who had intervention, 25 (86%) received iliac PTA/stenting, while 4 patients required inflow surgical reconstruction for nonfocal iliac disease demonstrated on operative arteriography. Duplex imaging correctly identified the need for concomitant outflow reconstruction/bypass in 11 of the 25 (44%) patients treated by iliac PTA/stenting. Primary and assisted patency rates of iliac PTA/stenting were 83% and 100% at 24 months by life-table analysis. Duplex imaging in patients with symptomatic aortoiliac occlusive disease can provide sufficient information to permit endovascular and surgical intervention without formal diagnostic arteriography in most patients.     

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.     

Long-term outcome in patients under 40 years after revascularization for chronic lower limb ischaemia.

BACKGROUND: In order to find out if surgical or endoluminal treatment changes the long-term results of atherosclerotic occlusive disease in patients of under 40 years of age we reviewed 17 consecutive patients. METHODS: Their mean age was 36.5. Patients with Buerger's disease or inflammatory arteriopathy were excluded. All patients were extremely heavy smokers. The indications for surgical procedures were disabling claudication (less than 100 meters) for 11 patients, rest pain for 4 patients and grangrene of a lower limb for 2 patients. The lesions were aorto-iliac in 12 cases and femoro-popliteal in 5. Ten surgical procedures were performed (5 aorto-femoral bypasses, 1 ilio-femoral bypass associated with an aorto-renal bypass, 2 femoropopliteal bypasses, 1 aorto-iliac endarteriectomy, 1 femoral endarteriectomy). On the other hand there were 7 endoluminal procedures (1 aortic, 4 iliac, 1 femoral and 1 popliteal). RESULTS: The mean follow-up was 97.3+/-50 months (range, from 34 to 216 months). Two patients died by 57 and 132 months respectively. At 5 years the survival rate was 94%; the primary patency rate was 59%; the secondary patency rate was 81% and the limb salvage rate was 94%. At 10 years these rates were respectively 94%, 44%, 54% and 75%. A total of 21 reoperations were performed. During follow-up 11 patients were better, 2 were stable and 4 were worse with 2 limbs lost. CONCLUSIONS: These bad results suggest keeping the surgical and endoluminal indications for patients younger than 40 years with threatened limbs.     

Kissing-stents技术治疗主-髂动脉闭塞症15例

目的 探讨kissing-stents(K型)技术腔内治疗主-髂动脉狭窄和闭塞性疾病的可行性.方法 回顾性分析2007年4月至2009年4月应用K型腔内成型技术治疗15例主-髂动脉狭窄闭塞性疾病患者的临床资料.其中男9例,女6例,平均66岁.全部病例有明显肢体缺血表现,其中:间歇性跛行11例(73%),平均距离88m.静息痛4例(27%),足趾坏死2例(13%).辅助检查提示:腹主动脉远端-双髂总动脉闭塞伴一侧股浅动脉局限性狭窄2例,双髂动脉狭窄伴闭塞3例,左侧髂总动脉闭塞伴双侧股浅动脉闭塞2例,右侧髂总动脉闭塞8例,其中4例伴有一侧股浅动脉狭窄和闭塞.全部患者ABI检查最低为0.0,最高为0.6,平均0.36±0.3.结果 15例患者应用K型技术均获成功,同时在双侧髂动脉内共植入40枚支架,平均每人植入2.7枚支架.其中15枚为自膨支架,25枚为球扩支架.治疗后血管造影显示,病变部位血管形态明显改善,管腔狭窄程度均<30%.病变血管近远端压力差平均为5 mm Hg.手术后肢体ABI测定:最低为0.5,最高为1.0,平均为0.8±0.2,与手术前相比平均提高0.44.全部患者的临床症状得到明显改善,平均住院日7 d.术后随访2年,原发性通畅率为87%,二次通畅率为94%.结论 应用腔内K型技术治疗主-髂动脉狭窄和闭塞性疾病是有效和安全的,可以明显提高手术的成功率,减少并发症的发生.     

Durability of renal artery stents in patients with transrenal abdominal aortic endografts

OBJECTIVE: The management of renal artery stenosis in patients with abdominal aortic aneurysms continues to be complex and technically challenging despite advances in endovascular therapy. There is growing concern about the durability of renal artery stents in the setting of transrenal abdominal aortic endografts. This study reports a single-center experience of renal artery stenting with transrenal abdominal aortic endografts for patients with renal artery stenosis. METHODS: All patients undergoing endovascular abdominal aortic aneurysm repair preceded or followed by renal artery stent placement between January 1999 and December 2005 were retrospectively reviewed from a prospectively gathered endovascular database. Patients were surveyed after renal stent procedures with multidetector computed tomography angiography or duplex sonography. The surveillance data were analyzed for primary patency of the renal artery stent at 6 months, incidence of complications, need for secondary interventions, and changes in creatinine clearance (CrCl). RESULTS: Sixty-two renal artery stents were placed in 56 patients (44 men, 12 women) with a mean age of 77.3 years (range, 61 to 94 years). Forty-one were placed before the endograft procedure, eight were placed during the endograft procedure, and 13 were placed postoperatively. There were no major or minor complications related to the renal artery stent procedures. Transrenal aortic endografts were used in 44 of the 56 patients, and 12 had devices with infrarenal fixation. The mean follow-up was 18.5 months (range, 1 to 73 months). The 6-month primary patency, which could be evaluated for 51 renal artery stents, was 97.4% (37/38) in patients with transrenal fixation and 84.6% (11/13) in patients with infrarenal fixation. The overall rate of in-stent restenosis was 8.5% (4/47) in the transrenal fixation group and 20.0% (3/15) in the infrarenal fixation group. The overall occlusion rate was 2.1% (1/47) in the transrenal fixation group and 0% (0/15) in infrarenal fixation group. Five (83.3%) of six patients underwent successful treatment of in-stent restenosis with placement of a new stent in all five cases. CrCl decreased in the total group by 4.2 +/- 11.8 mL/min, by 4.7 +/- 12.0 mL/min in patients with transrenal fixation, and by 2.2 +/- 11.0 mL/min in patients with infrarenal fixation. CONCLUSION: The presence of a transrenal aortic endograft did not affect the outcome of the renal artery revascularization procedure in this cohort. Renal artery stenting in the presence of transrenal abdominal aortic endografts appears to be a safe procedure without adverse effect on renal artery stent patency or renal function.