Percutaneous transluminal angioplasty and stenting for iliac artery occlusive disease.

Atherosclerotic iliac artery stenoses respond well to simple balloon angioplasty and have the best results of all of the peripheral vessels. Nonetheless, initial technical failures occur in as many as 20% of patients, most of which can be salvaged with intravascular stenting, as can many of the potential complications; however, even though the initial technical success rates for stenting approach 100%, stenotic recurrences within stents are not infrequent. Whether promising new concepts, such as brachytherapy, gene therapy, and endoluminal grafting, will have a durable impact on the results of iliac angioplasty is yet to be seen. Meanwhile, the excellent results of endoluminal treatment of patients with iliac artery occlusive disease, combined with the relatively low risk for complications compared with surgical revascularization, ensure an enduring role for this modality of treatment and a diminution in the fraction of patients requiring surgery to correct their iliac artery occlusive disease.     

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。     

The impact of combined iliac occlusive disease and aortic aneurysm on open surgical repair

ObjectiveSevere aortoiliac occlusive disease is a relative contraindication for endovascular aneurysm repair, owing to an association with high stent graft-related complication and reintervention rates in this population. Open AAA repair requiring aortofemoral bypass (AFB), however, may represent a unique population with differing outcomes from standard open repair. We sought to compare the demographic and procedural characteristics, as well as outcomes of patients undergoing standard intra-abdominal repairs (STD) versus those requiring AFB.MethodsUsing a prospectively maintained database, we retrospectively identified patients who underwent open AAA repair from 1994 to 2017. A total of 1087 consecutive cases were performed consisting of 981 STD (681 tube graft, 300 aortoiliac) and 106 AFB cases. Demographics, procedural data, postoperative complications, and long-term survival were analyzed.ResultsThe AFB cohort had more women (39.0 vs 22.8%; P = .001) and higher rates of hypertension (81.1 vs 69.8%; P = .015), chronic obstructive pulmonary disease (28.3 vs 17.4%; P = .006), and smoking (50.9 vs 36%; P = .002). The AFB group had smaller mean aortic (5.22 vs 5.77 cm; P = .001) and graft (17.08 vs 18.2 mm; P = .001) diameters. Proximal clamp position and blood loss were equivalent, although total anesthesia time was longer (295 vs 234 minutes; P = .001) in the AFB cohort. Overall 30-day postoperative morbidity (38.7 vs 24.8%; P = .002) was higher in the AFB group. Specifically, postoperative renal insufficiency (8.2 vs 3.4%; P = .032), wound infection (5.7 vs 1.2%; P = .005), and hematoma/seroma (5.7 vs 1.2%; P = .003) were more likely. Hospital length of stay was longer for AFB (11.9 vs 9.9 days; P = .007). The 30-day mortality (0.9% AFB vs 1.8% STD; P = .50) and major morbidity (17 vs 11.5%; P = .10) did not differ. Reintervention rate within 30 days of the initial surgery (12.3 vs 4.6; P = .001) and overall (33 vs 18.9%; P = .001) was higher in the AFB group. Long-term survival was lower in the AFB group (5-year survival: 63.1% AFB vs 71.9% STD; hazard ratio 0.76, log-rank P = .047). Multivariate regression analysis identified age, comorbid conditions, and aneurysm characteristics—rather than repair type—as independent predictors of 30-day reintervention and mortality at 5 years.ConclusionsPatients requiring AFB for AAA owing to associated iliac occlusive disease have more preoperative comorbidities, postoperative complications, a longer length of stay, reintervention rates and shorter 5-year survival. Patient and aneurysm characteristics rather than surgical repair type appear to be responsible for these differences. Nevertheless, 30-day mortality and major morbidity were comparable, making AFB an attractive alternative to endovascular aneurysm repair in patients with advanced iliac occlusive disease.     

Late iliac artery aneurysms and occlusive disease after aortic tube grafts for abdominal aortic aneurysm repair. A 35-year experience.

Controversy continues over whether patients treated with straight Dacron aortic tube grafts for an abdominal aortic aneurysm remain at significant risk for subsequent development of iliac aneurysm or occlusive disease. To address this issue, the authors performed a population-based analysis of 432 patients who had an abdominal aortic aneurysm diagnosed between 1951 and 1984. Aneurysm repair was performed eventually in 206 patients (48%). To ascertain differences in late development of graft-related complications, iliac aneurysms, and arterial occlusions, the authors compared all tube-graft patients with similar numbers of bifurcated-graft patients matched for age and year of operation. In the tube-graft group, no subsequent clinically evident or autopsy-proven iliac aneurysms or iliac occlusive disease were noted. Over a mean follow-up of 6 years (range, 4 to 18 years), new aortic aneurysms occurred in the proximal aorta in both tube and bifurcated-graft patients (5.0% and 2.5%, respectively). In contrast the cumulative incidence of graft-related complications was higher with a bifurcated prosthesis (12.8%) compared with a straight graft (5.0%) (p = 0.15). These problems generally occurred 5 to 15 years postoperatively and emphasize the need for long-term graft surveillance. The authors conclude that straight tube-grafts for repair of abdominal aortic aneurysms provide excellent late patency with minimal risk of subsequent iliac aneurysm development.     

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.     

Combined saphenous ablation and iliac stent placement for complex severe chronic venous disease

BACKGROUND: Severe chronic venous disease frequently has a complex pathophysiology. This study describes results after combined interventions to correct outflow obstruction and superficial reflux, even in the presence of deep venous reflux. METHODS: Between 1997 and 2005, 99 limbs in 96 patients had percutaneous iliofemoral venous stenting combined with great saphenous vein (GSV) stripping (39 limbs), or percutaneous GSV ablation performed by radiofrequency (27 limbs) or laser (33 limbs). Clinical severity score in CEAP was C4 in 51 limbs, C5 in eight limbs, and C6 in 40 limbs; median age was 56 years (range, 27 to 87 years); left-right limb ratio, 2.3:1; female-male ratio, 1.8:1; primary-secondary etiology, 58:41. Perioperative investigations included visual analogue pain scale (VAS), degree of swelling (grade 0 to 3); quality-of-life questionnaire; venous filling index in milliliters per second (VFI90), venous filling time in seconds (VFT), percentage in ambulatory venous pressure drop (AVP), duplex Doppler scanning, and radiologic studies. RESULTS: Clinical follow-up was performed in 97 (98%) of 99 for up to 5.5 years. Axial deep reflux was found in 27% (27/99). At least three venous segments were refluxing in 40% of limbs. Preoperative hemodynamic parameters reflected the presence of reflux and improved significantly (P < .01) after the procedure (VFI90, 3.8 to 2.3 mL/s; VFT, 11 to 16 seconds; AVP, 55% to 65%). No patients died, and the morbidity with endovenous GSV ablation was largely limited to ecchymosis and thrombophlebitis in the thigh area. Cumulative primary, assisted primary, and secondary stent patency rates at 4 years were 83%, 97%, and 97%, respectively. After treatment, limb swelling and pain substantially improved. The rate of limbs with severe pain (>or=5 on VAS) fell from 44% to 3% after intervention. Gross swelling (grade 3) decreased from 30% to 6% of limbs. Cumulative analysis showed sustained complete relief of pain (VAS = 0) and swelling (grade 0) after 4 years in 73% and 47% of limbs, respectively. Ulcers healed in 26 (68%) of 38 ulcerated limbs. Cumulative ulcer-healing rate was 64% at 48 months. All quality-of-life categories significantly improved after treatment. CONCLUSION: The single-stage combination of percutaneous venous stenting and superficial ablation in patients with severe chronic venous disease is safe, gives excellent symptom relief and improvement of quality of life, and a well-maintained ulcer-healing rate. It seems logical to initially perform multiple minimally invasive interventions rather than open surgery. Any associated deep reflux can initially be ignored pending clinical response to the combined intervention.     

血管腔内成形术治疗髂动脉硬化闭塞症

目的 探讨血管腔内成形术治疗髂动脉硬化闭塞症的临床疗效.方法 回顾性分析2002年12月至2008年12月收治的61例(76条血管)髂动脉硬化闭塞症患者的临床资料,其中男46例,女15例.平均年龄(67±11)岁.主要临床症状包括严重的间歇性跛行(跛行距离<100 m)38例,静息痛13例,肢/趾端溃疡10例.TASC A型病变29例,B型16例,C型11例,D型5例.应用导丝导管或超声消融开通闭塞段,行腔内支架置入术后随访.结果 61例患者71条血管成功开通(共置入63枚支架),开通率93%(71/76).成功者临床症状改善率100%.踝肱指数(ABI)由术前0.33±0.17提高到术后0.72±0.20,差异有统计学意义(P<0.05).随访51例,随访率83%.随访时间6-60个月,平均(26±14)个月.1年通畅率90%(TASC A、B组92%;TASC C、D组84%).3年通畅率75%(TASC A、B组80%;TASC C、D组63%);5年通畅率72%.结论 髂动脉硬化闭塞的腔内成形术较传统的血管重建手术创伤小、并发症低,近、中期通畅率相当.     

Repair of abdominal aortic aneurysms in patients with renal, iliac, or distal arterial occlusive disease

Appropriate preoperative vascular assessment of patients presenting with aortic aneurysms and arterial occlusive disease is essential to obtain the optimal results from aneurysm repair. The renal arteries should be evaluated in patients with hypertension or renal dysfunction, and stenosis must be addressed when seen on arteriograms. Hemodynamically significant lesions are candidates for bypass concomitant with aortic replacement. The stump pressure of a patent inferior mesenteric artery should be assessed intraoperatively, and bypass or reimplantation should be performed if colon ischemia might result from internal mesenteric artery ligation. If vasculogenic impotence is suggested by preoperative studies, meticulous nerve-sparing dissection and revascularization of the internal iliac arteries may result in recovery of erectile function in some patients. In all cases of aneurysm repair, the hypogastric circulation must be maintained through either direct revascularization or bypass to major collateral arteries. Iliac occlusive disease may be evaluated with several modalities, including physical examination, noninvasive laboratory testing, arteriography, and the papaverine test, to determine whether critical or subcritical stenoses are present. Aortic bifurcation grafts should be used to construct the distal anastomoses beyond areas of significant disease. The extent of lower-extremity occlusive disease directly affects the long-term patency of aortic replacement, and diligent follow-up is necessary for timely intervention to maintain patency of vascular reconstructions.     

腔内治疗在主髂动脉硬化闭塞症中的应用

目的探讨主髂动脉硬化闭塞症腔内治疗的技术要点及其疗效。方法回顾性分析主髂动脉硬化闭塞患者113例临床资料,其中男79例,女34例,年龄45岁～81(平均62.5)岁。TASCA型42例(37.17%),B型39例(34.51%),C型患者13例(11.50%),D型患者19例(16.81%)。腔内治疗经股动脉或肱动脉入路,采用通过闭塞段、球囊扩张、支架放置及股总动脉内膜剥脱等方法进行治疗。结果 107例患者主髂动脉闭塞病变获开通,开通率为94.7%。68例患者临床症状明显改善,39例中度改善,。平均随访(26±2.3)个月(6～54个月),术后6个月,1,2年的初次通畅率分别为82.76%,76.21%,67.66%,术后6个月,1,2年的二次通畅率分别为92.31%,81.67%,73.62%。结论对于主髂动脉硬化闭塞的患者,综合应用多种方法进行腔内治疗是一项安全有效的措施,可获得满意的临床疗效。     

Retroperitoneal inflow procedures for iliac occlusive vascular disease

We reviewed our experience over the past six years with retroperitoneal inflow procedures (aortofemoral and iliofemoral bypass grafts) in high-risk patients with aortoiliac occlusive disease. There were 57 limbs in 40 patients. Twenty percent of the patients were diabetic, 80% were smokers, 40% had heart disease, 54% had hypertension, and 25% had symptomatic chronic obstructive pulmonary disease. The average patient age was 64 years. There was no operative mortality and cumulative patency rate by life-table analysis at four years was 84%. The site of the proximal anastomosis (aorta vs iliac) or the configuration of the graft (unifemoral vs bifemoral) did not influence the patency rate. Retroperitoneal inflow procedures are an excellent alternative in patients who present an unacceptably high risk for standard aortofemoral reconstruction.     

Endovascular treatment of iliac occlusive disease: review and update

Use of endovascular interventions for arterial occlusive lesions continues to increase. With the evolution of the technology supporting these therapeutic measures, the results of these interventions continue to improve. In general, a comparison of techniques for revascularization of iliac occlusive diseases shows similar initial technical success rates for open versus percutaneous transluminal angioplasty. Angioplasty is often associated with lower periprocedural morbidity and mortality rates. Conversely, surgery frequently provides greater long-term patency, although late failure of percutaneous therapies may occur but still can be treated successfully with reintervention. The perpetual buildup of experience with angioplasty and stenting will eventually characterize its role in the management of occlusive disease. This review outlines the current consensus and applicability of endovascular management of iliac occlusive diseases.     

慢性髂动脉阻塞性疾病外科手术与介入治疗的比较与选择

目的:比较慢性髂动脉阻塞性疾病外科手术与介入治疗的疗效、并发症及随访结果,以指导该类疾病的治疗选择。方法:通过随机分组对67例慢性髂动脉阻塞患者分别进行外科手术和介入治疗,对其治疗效果、并发症及随访结果进行分析和比较。结果:外科手术组行人工血管转流30例(其中解剖位血管重建24例,左右股-股动脉转流6例),补片成形4例。介入治疗组行单纯球囊扩张7例,球囊扩张联合支架置入23例,3例介入治疗失败。术后30 d,外科手术组和介入治疗组重建血管通畅率分别为100%和96.7%,总体有效率为97.1%和84.8%;外科手术组和介入治疗组围手术期并发症的发生率分别为35.3%(12/34)和20.0%(6/30);随访时间为13～65个月,术后第1年两组的重建血管通畅率和症状缓解率无统计学差异(均P>0.05),第2年开始,外科手术组血管通畅率、ABI明显高于介入治疗组,同时间隙性跛行、静息痛等方面也好于介入治疗组(均P<0.05)。结论:外科手术和介入治疗对慢性髂动脉阻塞性疾病均可取得理想疗效,外科手术远期疗效更好,但手术风险较介入治疗大。对于高龄、全身状况差不能耐受外科手术的患者,介入治疗是理想的选择。     

膝下动脉狭窄或闭塞血管腔内成形术的治疗

目的探讨血管腔内成形术(PTA)治疗膝下动脉狭窄或闭塞的临床疗效。方法回顾性分析2007年6月至2009年7月我科采用PTA治疗的34例(38条患肢)膝下动脉狭窄或闭塞患者的临床资料。结果 35条患肢PTA治疗成功,技术成功率为92%(35/38),平均随访8(3～18)个月,踝肱指数(ABI)由术前的0.41±0.12上升至0.82±0.05(P0.01),总的肢体保全率为91.4%。无住院死亡,并发症发生率为13%(5/38)。结论 PTA治疗膝下动脉狭窄或闭塞短期内具有较好的临床疗效,可以明显减少截肢率,是一种治疗膝下动脉病变至下肢缺血有效且安全的方法。     

Drug-eluting stents for infrainguinal occlusive disease: progress and challenges

High restenosis rate is still the major limitation of peripheral arterial interventions. Within the last years, drug-eluting stents have gained wide acceptance in the coronary arteries, however, these devices are not currently available for arteries outside the coronary vasculature. This article summarizes the special role of the superficial femoral artery in restenosis, with efforts being made to reduce the restenosis rate in this artery, focusing on stents and drug-eluting stents.