Endovascular intervention of aortoiliac occlusive disease in high-risk patients using the kissing stents technique: Long-term results

Midterm results of kissing stent reconstruction of the aortoiliac bifurcation

Purpose

One subset of peripheral arterial disease is aortoiliac occlusive diseases (AIOD). AIOD is the term for all arterial lesions between the infrarenal distal aorta and common femoral artery. Implantation of kissing stents (KS) with covered stents (CS), bare-metal stents (BMS) is one of the endovascular treatment (ET) modalities for AIOD involving aortic bifurcation. In this study, we report the outcomes of the KS technique in infrarenal AIOD.

Methods

Between January 2014 and September 2017, 31 patients who underwent ET were treated with KS technique either with balloon-expandable BMS or balloon-expandable CS. Technical details, clinical success, complications, and patency at follow-up were documented.

Results

The majority of patients were male (77.4%), and the median age was 62 years (range, 45-78 years). All patients were classified according to the TASC II criteria. Eight patients (25.8%) were classified as TASC B. Fifteen patients (48.4%) were classified as TASC C, and 8 patients (25.8%) were classified as TASC D. These 23 patients were classified as complex AIOD group. BMS was used in 17 patients (54.8%), and CS was used in 14 patients (45.2%). Technical and clinical success was achieved in 100% of treated cases. The median follow-up was 24 months (range, 24-34 months). Primary patency rates at 12, 18, and 24 months after ET were 100%, 96.8%, and 90.3%, respectively.

Conclusion

We found that the KS technique has satisfying 24-month results, even in complex AIOD lesions, with high technical success and acceptable midterm patency. Key Words: Aorta, Arterial occlusive diseases, Endovascular procedures, Iliac artery, Stents.

Midterm outcomes of endovascular treatment with bare metal stents for Leriche syndrome patients

OBJECTIVES

This study was undertaken to evaluate the acute and midterm results of endovascular treatment with bare metal stents (BMS) for Leriche syndrome patients.

METHODS

Patients with Leriche syndrome treated with BMS from August 2008 to May 2017 were included in the study and followed up. The primary endpoints were primary restenosis-free survival rates at 1, 2 and 3 years. The secondary endpoints were secondary restenosis-free and freedom from target lesion revascularization survival rates at 1, 2 and 3 years; technical success rate; complication rate; procedure-related mortality rate; and clinical status improvement at follow-up.

RESULTS

Twenty patients were included and the follow-up duration was 34.7 ± 18.7 months (0-86 months). The 1-, 2- and 3-year primary restenosis-free survival rates were 94.4%, 88.1% and 73.5% and the secondary patency rates were 94.4%, 94.4% and 86.6%, respectively. The freedom from target lesion revascularization survival rates of patients at 1, 2 and 3 years were 94.4%, 88.1% and 79.3%, respectively. The aortoiliac lesions were successfully treated with BMS bilaterally in 17 patients (85.0%) and unilaterally in another 3 patients (15.0%). The complication rate was 10.0% and the procedure-related mortality rate was 0%. Mean ankle-brachial index increased significantly from 0.43 ± 0.20 before the procedure to 0.95 ± 0.21 after the procedure (P < 0.001), and to 1.00 ± 0.19 at the end of the follow-up (P < 0.001). Improvement in symptoms occurred in most patients soon after the endovascular procedure (95.0%) and at follow-up (88.2%).

CONCLUSIONS

Endovascular treatment with BMS is effective and safe for patients with Leriche syndrome according to 3-year follow-up results.

Effectiveness and long-term outcomes of different crossing strategies for the endovascular treatment of iliac artery chronic Total occlusions

Background

The iliac occlusive disease is usually treated with endovascular procedures in recent years. The effectiveness of different crossing approaches for these occlusions is not precisely known. We performed a retrospective study to explore the optimal crossing approach (antegrade versus retrograde) for iliac artery chronic total occlusions (CTOs) and to examine the long-term outcomes.

Materials and methods

We performed a study on 107 patients (116 iliac occlusive lesions, mean age 64.0 ± 11.1, 88 men) who underwent an iliac CTO endovascular intervention attempted with the use of both crossing strategies but were managed with one final crossing approach between August 2012 and August 2018. Baseline data, procedural characteristics, and outcomes were described. A Cox proportional hazard model and Kaplan-Meier method were developed to assess the differences in the two crossing approaches in terms of the 1-year and 5-year primary patency rates, target lesion revascularization (TLR) and major adverse limb events (MALEs).

Results

Common iliac artery (CIA) lesions were more likely to be crossed successfully in the retrograde direction (6.8% for antegrade vs. 20.9% for retrograde, p = 0.005), while lesions in the CIA/ external iliac artery (EIA) were more prone to be crossed successfully in the antegrade direction (58.9% for antegrade vs. 39.5% for retrograde, p = 0.016). There were no significant differences in the crossing approach for EIA lesions between the two groups. The two crossing approaches were associated with similar estimates of 1- and 5-year primary patency, TLR and MALE rates.

Conclusion

The antegrade approach was associated with a higher rate of successful crossing in CIA/EIA CTO lesions, while the CIA-only CTOs were more likely to be crossed successfully with the retrograde approach.

Comparison of results between kissing stent and aortic bifurcated bypass in aortoiliac occlusive disease

OBJECTIVE

Kissing stent (KS) technique has been used as an alternative to aortic bifurcated bypass surgery (ABBS) for aortoiliac occlusive disease (AIOD). We aimed to compare the results of ABBS and KS in AIOD.

METHODS

Medical records of patients treated with ABBS and KS between March 2011 and December 2016 in a single center were retrospectively analyzed. The patients' characteristics and clinical outcomes were evaluated.

RESULTS

Patients who underwent ABBS had a more common history of smoking (P = 0.04) and lower body mass index (P = 0.02). A significant difference was observed between the two groups in terms of the TransAtlantic Inter-Society Consensus II classification (P < 0.01). A significant difference was observed between the two groups of improvement in postoperative mean ankle-brachial indexes (ABI) (ABBS: 0.57 ± 0.24 vs KS: 0.41 ± 0.18, P = 0.01). A significant difference was observed between the combined treatments of the two groups (P < 0.01). Primary patency rates of the ABBS and KS groups at 1, 2, and 3 years were 90.1% and 100%, 82.6% and 90.6%, and 82.6% and 90.6%, respectively (P = 0.637). Primary assisted patency rates of the ABBS and KS groups at 1, 2, and 3 years were 90.1% and 100%, 82.6% and 95.7%, and 82.6% and 95.7%, respectively (P = 0.110). Secondary patency rates of the ABBS and KS groups at 1, 2, and 3 years were 93.8% and 100%, 93.8% and 95.7%, and 93.8% and 95.7%, respectively (P = 0.512).

CONCLUSION

ABBS in AIOD remains an important revascularization option whenever endovascular treatment is not feasible.

Meta-analysis of Individual Patient Data After Kissing Stent Treatment for Aortoiliac Occlusive Disease

PURPOSE

To evaluate short- and long-term technical and clinical outcomes after kissing stent treatment of aortoiliac occlusive disease (AIOD) based on an individual participant data (IPD) meta-analysis.

MATERIALS AND METHODS

A search of the Scopus database identified 156 articles on KS treatment of AIOD; of these 22 met the inclusion criteria. Authors of 19 articles with contact information were approached to join an IPD consortium. Eight author groups responded and 5 provided anonymized data for merging into an IPD database. The number of included procedures was equal before and after 2005. The primary study outcome was the cumulative patency at 24 months. Secondary outcomes were patency at up to 60 months, complications, and changes in Rutherford category and ankle-brachial index. The predictive value of stent protrusion length, pre-/postdilation, stent type, and patient demographics on primary patency were examined with Cox proportional hazard modeling; outcomes are reported as the hazard ratio (HR). The Kaplan-Meier method was employed to estimate patency rates.

RESULTS

In total, 605 (40.9%) of 1480 patients presented in the literature were included in the IPD analysis. The indication for intervention was intermittent claudication in 84.2% and critical limb ischemia in 15.8%. Lesions were classified as TransAtlantic Inter-Society Consensus (TASC) A or B in 52.8% and TASC C and D in 47.2%. The overall primary patency estimate was 81% at 24 months. Primary patency significantly increased after 2005 (p=0.005). Cox regression analysis revealed only age as a significant predictor of sustained primary patency (HR 0.60, p<0.005). Any previous endovascular intervention (HR 2.52, p=0.02) was the main predictor for loss of secondary patency; history of cardiovascular disease (HR 0.27, p=0.04) was the main predictor of sustained secondary patency.

CONCLUSION

The kissing stent technique has a good safety profile and acceptable patency rates up to 2 years, even in TASC C and D lesions, supporting an endovascular-first approach for AIOD.

Stent Protrusion >20 mm Into the Aorta: A New Predictor for Restenosis After Kissing Stent Reconstruction of the Aortoiliac Bifurcation

Purpose: To determine the long-term patency of aortoiliac kissing stents and to identify predisposing factors for the development of in-stent restenosis (ISR). Methods: A retrospective analysis was conducted of 105 patients (median age 60.9 years; 64 women) with symptomatic aortoiliac occlusive disease who had kissing stents implanted between 2001 and 2015. The indication for kissing stents was severe claudication in 91 (86.7%) patients and critical limb ischemia in 14 (13.3%). Lesions were TASC A in 52 (49.5%), B in 29 (27.6%), C in 4 (3.8%), and D in 20 (19%) patients. Twenty-five (23.8%) patients had heavily calcified lesions. In all, 210 stents were deployed [180 (85.7%) self-expanding and 30 (14.3%) balloon-expandable]. Follow-up included clinical evaluation, ankle-brachial index measurement, and duplex ultrasonography. Results: The median follow-up was 45 months. The primary patency rates were 93%, 86%, and 77% at 12, 24, and 60 months, respectively. Significant ISR developed in 23 (21.9%) patients (12 unilateral and 11 bilateral). Univariate Cox regression analysis revealed older age [hazard ratio (HR) 0.5, 95% confidence interval (CI) 0.31 to 0.81, p=0.004] and larger aortic diameter (HR 0.42, 95% CI 0.25 to 0.7, p<0.001) to be variables favoring long-term patency, while a longer aortic stent segment (HR 1.56, 95% CI 1.16 to 2.09, p=0.003) and a larger discrepancy between the summed stent diameters and the aortic diameter (HR 1.64, 95% CI 1.01 to 2.65, p=0.043) were associated with ISR development. Multivariate analysis showed a longer aortic stent segment to be the only significant determinant of ISR (HR 1.44, 95% CI 1.02 to 2.01, p=0.035). Conclusion: The kissing stent technique can be performed with good long-term patency. Patients whose iliac stents protrude too far into the aorta need closer follow-up.

Endovascular Management of Flush Common Iliac Artery Occlusive Disease: Challenges and Solutions

The aim of this study was to assess the difficulties met with possible recommendations in management of flush common iliac artery occlusive disease (FCIAOD). This a prospective study assessing FCIAOD along the period of 24 months. We defined FCIAOD as more than 90% occlusion of diameter of common iliac artery (CIA) with less than 2 mm patent iliac stump from its origin from the abdominal aorta. Our study included 51 cases. Technical success was achieved in 47 patients (92%); 82.5% of cases were done via two accesses (65% of cases were done using bilateral femoral). Primary stenting was done in all cases. Sixty-eight percent of cases were treated by unilateral stents (81.3% of them were done using self-expandable) and 32% of cases were treated by kissing stents (50% using self-expandable). Prestent dilatation was selectively used in 77% of cases. Follow-up (12 months) revealed primary patency of 82.5% and secondary patency was 98% with no amputation done. Mortality rate was 4%. Endovascular treatment provides a successful option for the management of FCIAOD with a technical success rate of 92%, the option of selective use of prestent dilatation. FCIAOD does not preclude the use of unilateral stent in CIA, which can be completed to kissing stents if needed.

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.

Increasing role of interventional cardiologists for peripheral vascular disease

Improvements in the design of endovascular devices and technical skills of interventionalists have opened new possibilities for patients with a wide range of peripheral vascular diseases. In lower extremity peripheral artery disease, percutaneous treatments have become the predominant revascularization strategy for simple and complex lesions. Newer generations of stents and drug-coated balloons have demonstrated strong potential in the treatment of femoropopliteal and infrainguinal diseases. One of the most dramatic advances in the recent past has been endovascular repair of thoracic and abdominal aortic aneurysms, which has become the preferred approach in lieu of open surgical repair. Contemporary trials have established the safety and effectiveness of carotid stenting in selected patients with severe stenosis. Endovascular treatments for venous occlusive disease have long been underutilized, but their effectiveness is being increasingly recognized. This review covers new endovascular procedures performed by interventional cardiologists for peripheral vascular diseases.

Long-term results of stenting of the aortic bifurcation

BACKGROUND

To evaluate the long-term results in a multicentric continuous series of narrowing lesions of the aortic bifurcation treated with a kissing stent.

METHODS

From January, 1st 1999 to the December, 31st 2001, all of the patients (n = 80) presenting with stenosis of the aortic bifurcation (n = 15) and/or the 2 common iliac arteries (n = 65), treated with a kissing stent, in 8 teaching hospitals were collected retrospectively. The risk factors were smoking (91%), dyslipidemia (60%), arterial hypertension (42%) and diabetes (27%). In 84% of cases, the indication for treatment was claudication. The lesions were stenotic < 70% (n = 76) and/or thrombotic (n = 18). The associated lesions were external iliac stenoses (n = 21), common femoral stenoses (n = 19), femoro-popliteal stenoses (n = 42), arteriopathy in the leg (n = 35). Follow-up was clinical examination and Doppler US scan.

RESULTS

The success rate of the technique was 89%. There were 4 cases (5.3%) of residual stenosis and 4 cases (5.3%) of dissection. The length of the lesions treated in the aorta and the iliac arteries was respectively 17.1 ± 7 and 17.3 ± 9 mm. The stents were all placed as kissing stents, and had a mean diameter and a mean length of 13.75 mm and 56 mm in the aorta and 9 mm and 48 mm in the iliac arteries, respectively. At 5 years, 19 patients had required repeat angioplasty in the treated area, and 13 had undergone open surgery. Primary and assisted primary patency at 5 years were 64.5% and 81.8%, respectively.

CONCLUSION

Long-term follow-up of endovascular treatment with kissing stents for stenosis of the aortic bifurcation shows that this technique gives good results, though it does not justify doing away with classical revascularisation surgery, in a population with major cardiovascular risk factors.

T-stenting with small protrusion technique (TAP-stenting) for stenosed aortoiliac bifurcations with small abdominal aortas: an alternative to the classic kissing stents technique

PURPOSE

To report the feasibility and midterm results of aortic bifurcation reconstruction in patients with small abdominal aortas using commercially available stents applied in a modified T-stenting technique adapted from coronary angioplasty.

METHODS

Twenty-three patients (16 men; mean age 52.4 years) with lower limb ischemia (Fontaine stage IIb or III) and distal abdominal aortas <14 mm in diameter were treated for 39 common iliac artery and 16 aortic stenotic lesions involving the aortic bifurcation. A large, self-expanding stent was implanted from the lower aorta to one iliac branch, followed by deployment of a balloon-expandable stent in the contralateral iliac artery such that its proximal edge protruded a few millimeters through the struts of the self-expanding stent into the aorta [TAP (T And Protrude)-stenting technique]. Follow-up clinical, Doppler ultrasound, and computed tomography examinations were scheduled for each patient.

RESULTS

Angiographic success was obtained in all 23 patients, who received 23 self-expanding aortomonoiliac stents (mean diameter 13.5 mm) and 22 balloon-expandable stents (mean diameter 8.14 mm) in the contralateral iliac branch. No complications were reported. At a mean 16.3-month follow-up (range 2-60), clinical and ankle-brachial index (0.6±0.2 at baseline versus 1.04±0.1, p<0.01) improvement was observed in all patients. All stents were patent (patency rate 100%). Two late technical failures of the contralateral stent were observed (incomplete dilation requiring angioplasty and incomplete protrusion without any hemodynamic impact).

CONCLUSION

The TAP-stenting technique adapted to the aortoiliac bifurcation appears to be feasible, with satisfactory early and midterm patency rates in patients with small abdominal aortas. Larger series with longer follow-up times are necessary.

Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation

PURPOSE

To review the outcomes with the use of balloon-expandable covered iliac kissing stents as compared with bare metal stents in the treatment of atherosclerotic disease at the aortic bifurcation.

MATERIALS AND METHODS

A review of consecutive patients from a single institution with atherosclerotic occlusive disease at the aortic bifurcation treated with balloon-expandable kissing stents was performed between January 1, 2002, and September 1, 2007. Fifty-four patients were identified and divided into two groups: those with bare metal stents and those with covered stents. Technical and clinical success (Fontaine classification), complications, and patency at follow-up were documented.

RESULTS

Twenty-six patients (17 men, nine women; mean age, 61 years; age range, 39-79 years) received covered stents and 28 patients (15 men, 13 women; mean age, 61 years; age range, 38-82 years) received bare metal stents. Technical success was achieved in 100% of patients in both groups. Major complications occurred in three of the 26 (11%) with covered stents (P = .66) and two of the 28 patients (7%) with bare metal stents. The median follow-up was 21 months (20 months for covered stents vs 25 months for bare metal stents; range, 1-62 months). Twenty-two of the 26 patients (85%) with covered stents had sustained improvement in clinical symptoms during the follow-up period compared with 15 of the 28 patients (54%) with bare metal stents (P = .02). Primary patency rates at 1 and 2 years were 92% and 92%, respectively, for covered stents and 78% and 62% for bare metal stents (P = .023).

CONCLUSIONS

The use of covered balloon-expandable kissing stents for atherosclerotic aortic bifurcation occlusive disease provides superior patency at 2 years as compared with bare metal balloon-expandable stents.

Endovascular treatment of peripheral vascular disease

Peripheral arterial disease (PAD) affects about 27 million people in North America and Europe, accounting for up to 413,000 hospitalizations per year with 88,000 hospitalizations involving the lower extremities and 28,000 involving embolectomy or thrombectomy of lower limb arteries. Many patients are asymptomatic and, among symptomatic patients, atypical symptoms are more common than classic claudication. Peripheral arterial disease also correlates strongly with risk of major cardiovascular events, and patients with PAD have a high prevalence of coexistent coronary and cerebrovascular disease. Because the prevalence of PAD increases progressively with age, PAD is a growing clinical problem due to the increasingly aged population in the United States and other developed countries. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, endovascular practice, percutaneous transluminal angioplasty with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably. In this monograph we discuss current endovascular intervention for treatment of occlusive PAD, aneurysmal arterial disease, and venous occlusive disease.

Kissing stents in the aortic bifurcation--a valid reconstruction for aorto-iliac occlusive disease

OBJECTIVE

To evaluate outcome and patency predicting factors of kissingstent treatment for aorto iliac occlusive disease (AIOD).

METHODS

Patients treated with kissingstents for AOID between 1995 and 2004 at a tertiary referral center were identified through local databases. Chart review and preoperative images were used for TASC and Fontaine classification. Follow-up consisted of clinical exams, ABI and/or duplex. Patency rates were estimated by Kaplan-Meier analysis, and Cox multivariate regression was used to determine factors associated with patency.

RESULTS

173 consecutive patients (46% male, mean 64 years) were identified. TASC distribution was: A 15%, B 34%, C 10%, D 41%. Mean follow-up was 36 months (range: 1-144). 30-day mortality was 1% (2 patients), and 1-year survival was 91% (157 patients). 2 patients underwent late, open conversion and 13 patients suffered minor puncture site complications. Primary, assisted primary and secondary patency was: 97%, 99% and 100%, and 83%, 90% and 95% at twelve and 36 months respectively. There was no significant difference in patency between the TASC groups. Patency was significantly worse for patients in Fontaine class III.

CONCLUSIONS

Aortoiliac kissing stents is a valid alternative to open repair for TASC A-D lesions. The procedure has low mortality and morbidity and good patency at 3 years.

Current Treatment of Peripheral Arterial Disease

Despite advances in medical therapies to help prevent the development of atherosclerosis and improve the management of patients with established peripheral arterial disease (PAD), the prevalence of PAD and associated morbidity remains high. Over the past decade, percutaneous revascularization therapies for the treatment of patients with PAD have evolved tremendously, and a great number of patients can now be offered treatment options that are less invasive than traditional surgical options. With the surgical approach, there is significant symptomatic improvement, but the associated morbidity and mortality preclude its routine use. Although newer percutaneous treatment options are associated with lower procedural complications, the technical advances have outpaced the evaluation of these treatments in adequately designed clinical studies, and therapeutic options are available that may not have been rigorously investigated. Therefore, for physicians treating patients with PAD, an understanding of the various therapies available, along with the inherent benefits and limitations of each treatment option is imperative as a greater number of patients with PAD are being encountered.

Standards for the Endovascular Management of Aortic Occlusive Disease

Occlusive disease of the infrarenal aorta and aorto-iliac arteries can be safely treated by minimally invasive therapy and is now widely available. The aim of this article is to produce standards for the management of these patients using current endovascular techniques.

Endovascular Treatment of Peripheral Vascular Disease

An estimated 10 million people in the U.S. have symptomatic peripheral arterial disease (PAD); 20 to 30 million have asymptomatic PAD. The prevalence of intermittent claudication increases with age, affecting >5% of patients over 70. The incidence of claudication doubles or triples in patients with diabetes. As people grow older, symptoms from peripheral vascular disease increasingly limit daily activity. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, advances in minimally invasive percutaneous interventions have made endovascular procedures the primary modality for revascularization in most patients. Compared with open surgical procedures, endovascular interventions offer comparable or superior long-term rates of success with very low rates for morbidity and mortality. Furthermore, most of these interventions are performed on an outpatient basis, reducing hospital stays considerably. In this monograph we discuss current endovascular interventions for treating occlusive PAD, aneurysmal arterial disease, and increasingly common venous occlusive diseases.

Aortoiliac Kissing Stents:Long-term Results and Analysis of Risk Factors Affecting Patency

PURPOSE

To present the early and long-term results of aortoiliac kissing stents implantation and evaluate the risk factors affecting patency.

METHODS

The data were retrospectively reviewed on 68 patients (64 men; mean age 55+/-11, range 32-77) who underwent kissing stents implantation during a 12-year period. The majority of patients (64, 94%) had claudication; 4 patients had rest pain. All were smokers. There were bilateral or unilateral stenoses in 42 (62%) patients, and unilateral occlusion and contralateral stenosis in 26 (38%). Lesions were treated with simultaneous implantation of self-expanding (n=52) or balloon-expandable (n=16) stents. After the procedure, patency was determined with Doppler ultrasonography or angiography at 1, 3, 6, and 12 months and annually thereafter. Primary, assisted primary, and secondary patency rates were calculated with Kaplan-Meier analysis on an intention-to-treat basis, and risk factors affecting the patency rates were determined with the Cox regression analysis.

RESULTS

All procedures were technically and clinically successful. Complications occurred in 12%, but none required surgery. The follow-up period was 35+/-31 months. Primary, assisted primary, and secondary patency rates, respectively, were 76%, 90%, and 94% at 1 year; 63%, 86%, and 92% at 3 years; and 63%, 64%, and 81% at 5 years. In multivariate analysis, age <50 years and presence of iliac occlusion were identified as risk factors for reduced primary and assisted primary patency; a crossed configuration of kissing stents was identified as a risk factor for reduced primary patency.

CONCLUSION

Implantation of kissing stents is a safe and effective alternative in the treatment of aortoiliac obstructions. However, overall primary and assisted primary patency rates are inferior to those reported for surgery. Long-term patency comparable to surgery may be obtained in patients >50 years and in those without an iliac occlusion, particularly if a favorable stent configuration is achieved.

Hybrid treatment for juxtarenal aortic occlusion: Successful revascularization using iliofemoral semiclosed endarterectomy and kissing-stents technique

A 53-year-old man with a significant respiratory history waiting for lung transplantation presented with severe bilateral buttock and thigh claudication. Angiography revealed severe stenosis of the left renal artery and total occlusion of the infrarenal abdominal aorta and iliac vessels. Via a bilateral surgical femoral exposure, we performed semiclosed endarterectomy of the iliofemoral vessels and percutaneous transluminal angioplasty stenting of the infrarenal aorta with two Palmaz stents and percutaneous transluminal angioplasty "kissing stents" of the iliac arteries with three Luminexx stents bilaterally. Completion angiography showed successful complete recanalization of the aortoiliofemoral axis. Palpable distal pulses were restored. A combined surgical and endovascular approach should be considered a viable alternative to laparotomy in selected patients with total juxtarenal aortic occlusion.