Comparison of conventional angioplasty with the Palmaz stent in the treatment of abdominal aortic stenoses from the STAR registry. SCVIR Transluminal Angioplasty and Revascularization

Endovascular treatment of infrarenal abdominal aortic lesions with or without common iliac artery involvement

PURPOSE

To evaluate the results of stent placement for obstructive atherosclerotic aortic disease with or without involvement of the common iliac artery.

MATERIALS AND METHODS

Forty patients had self-expanding stents primarily or after balloon dilatation in the abdominal aorta between January 2005 and May 2011. All patients had trouble walking. Follow-up examinations were performed with clinical visits; these included color Doppler ultrasonography and computed tomographic angiography.

RESULTS

Technical, clinical, and hemodynamic success was achieved in all patients. None of the patients underwent reintervention during the follow-up period, which ranged from 3 months to 6 years (median 24 months). Nine complications occurred in six patients. Of the nine complications, four were distal thromboembolisms, which were successfully treated with catheter-directed thrombolysis or anticoagulation therapy.

CONCLUSION

Endovascular treatment of the obstructive aortic disease using self-expanding stents was safe and effective, with high technical success and long-term patency. Thromboembolic complications were high even though direct stenting was considered protective for thromboembolism formation. Particularly for infrarenal aortic stenosis, it can be recommended as the first-line treatment option for patients with obstructive atherosclerotic aortic disease.

Endovascular management of aortoiliac occlusive disease

Patients with aortoiliac occlusive disease (AIOD) may be asymptomatic or may have intermittent claudication or critical limb ischemia. Treatment options for AIOD include management of risk factors, endovascular intervention, and/or surgical revascularization.

Low-profile primary stent placement for the treatment of focal calcified ulcerated stenosis in the infrarenal aorta

PURPOSE

To analyze the immediate and midterm success of low-profile stent placement in calcified ulcerated lesions of the infrarenal aorta in patients with arterial occlusive disease.

MATERIALS AND METHODS

In this prospective case series, 13 symptomatic patients (eight men, five women; mean age, 64.8 years +/- 12.1; age range, 44-84 years) with focal calcified ulcerated stenoses of the infrarenal aorta were treated with stent placement by using a low-profile technique in a radiology intervention center during a 4-year period. Clinical examinations and duplex ultrasonography were used to evaluate the stents? patency and clinical success. Kaplan-Meier graphs were calculated to analyze the freedom-of-symptom rate.

RESULTS

The initial technical success rate was 92% (12 of 13 patients). Due to extended calcifications, a residual stenosis of 50%-60% remained in one patient. No peri-interventional complications occurred. The mean follow-up was 26 months (range, 5-53 months). During follow-up, one patient had a restenosis after 7 months and presented clinically with Fontaine stage IIb. Two patients had iliac and/or femoral stenoses, and both presented with Fontaine stage IIb. One patient's symptoms originated from the lumbar spine. Primary patency and primary clinical success rates were 85% and 69%, respectively. According to Kaplan-Meier tables, the freedom-from-symptom rates were 92%, 84%, 73%, and 63% at 0, 7, 12, and 21 months, respectively.

CONCLUSIONS

Low-profile stent placement in calcified, ulcerated lesions of the infrarenal aorta is an effective and safe treatment for symptomatic stenoses in patients with arterial occlusive disease after a mean follow-up of 26 months.

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.

Primary stenting in the treatment of focal atherosclerotic abdominal aortic stenoses

AIM

To evaluate the results of primary stent placement in focal atherosclerotic aortic stenoses using balloon expandable stents.

MATERIALS AND METHODS

Twenty-six primary balloon expandable stent placements in the abdominal aorta were performed and reviewed. All the aortic stenoses were atherosclerotic. Patients were followed up by ankle/brachial pressure indices (ABPI) and Doppler ultrasound (US) at 24h after procedure and at 12 and 24 months. Follow-up angiograms were performed at 12 months.

RESULTS

Twenty-six stents in 26 patients were placed in the infrarenal aorta. All procedures were technically successful and immediate clinical success was obtained. The mean ABPI significantly improved from 0.52+/-0.10 to 0.94+/-0.09 within 24h after procedure, and remained at 0.90+/-0.12 between 12 and 24 months follow-up (mean 18 months). There was full haemodynamic success at hospital discharge and at 12 and 24 months after the procedure. Clinical success at 12 and 24 months (mean 18 months) was defined as an improvement in the Fontaine classification by at least one class compared with the pre-procedure class and was shown to be 100%.

CONCLUSION

In summary, we report that primary stenting is a safe and effective alternative to surgery in cases of symptomatic stenosis of the infrarenal abdominal aorta. The excellent intermediate term results suggested that we would recommend primary stenting as the treatment of choice for focal atherosclerotic stenoses of the infrarenal aorta in selected patients.

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.

Primary Endovascular Stent Placement for Focal Infrarenal Aortic Stenosis: Long-term Results

PURPOSE

The objectives of this retrospective study were to determine the technical success, safety, and long-term results of primary stent implantation in infrarenal aortic stenosis.

MATERIALS AND METHODS

A total of eight atherosclerotic stenoses and one occlusion of the infrarenal aorta (ie, midaortic syndrome) were treated with endoluminal stent placement after balloon angioplasty. Aortoiliac lesions were excluded. Technical success and patency were assessed.

RESULTS

Primary technical success in percutaneous transluminal angioplasty and subsequent stent placement was achieved in all patients. No complications occurred, and no morbidity was encountered. Primary clinical patency rates were 100% on all follow-up examinations. Long-term results with a mean follow-up of 110 months (range, 99-117 months) were recorded in seven patients; one patient had died and one was lost to follow-up.

CONCLUSIONS

In view of the excellent initial results and promising long-term follow-up data in a small series, stent placement after predilation in properly selected patients with isolated infrarenal aortic stenosis appears to be a promising, durable treatment. It should be considered as a primary method of treatment.

Long-term Results After Primary Stenting of Distal Aortic Stenosis

PURPOSE

To review the long-term results of primary stent placement in the distal aorta above the bifurcation.

METHODS

Fourteen patients (8 men; mean age 62 years, range 46-82) underwent primary stent implantation performed by an interdisciplinary radiosurgical team. In 10 patients, a long-term follow-up examination consisting of patient history, clinical examination, and duplex sonography was performed. The ankle-brachial index (ABI) for the posterior tibial artery was calculated on the basis of Doppler pressure measurements.

RESULTS

The clinical success rate at the first follow-up examination (mean 2.9 months, range 2.1-4.4) was 100% (n = 14). The mean baseline ABI of 0.64 +/- 0.12 had risen to 1.02 +/- 0.10 (p < 0.0001). At midterm follow-up (mean 22.8 months, range 14-42) in 12 patients, the ABI was 0.96 +/- 0.12 (p < 0.0001 versus baseline). At a mean 86 months (range 51-119) after stent treatment, the ABI in 10 patients was 0.90 +/- 0.20 (p < 0.0001 versus baseline). Over the long term, the clinical success rate was 70%. Deterioration was due to the progression of atherosclerosis distal to the aorta; duplex sonography showed no aortic restenosis or occlusion.

CONCLUSION

In view of the excellent long-term results in our small series, primary stent placement in focal abdominal aortic stenosis in properly selected patients is a durable treatment. In addition, the mortality and morbidity risks are markedly reduced compared with open surgery.

Endovascular Management of Isolated Infrarenal Aortic Occlusive Disease is Safe and Effective in Selected Patients

OBJECTIVE

To examine the safety and efficacy of endovascular management of isolated infrarenal aortic occlusive disease within our centre.

DESIGN AND METHODS

Retrospective analysis of all patients who underwent endovascular treatment of occlusive disease that is confined to the infrarenal aorta between September 1993 and November 2004.

RESULTS

Primary aortic stenting was carried out in 16 women and five men using self-expanding (12 patients) and balloon expanding stents to treat both occlusions (six) and stenoses (15). Indications included intermittent claudication (13), critical limb ischaemia (six), and distal embolisation (three). Significant postoperative complications within 30 days were noted in three, including one death. Fifteen patients completed 1-year follow-up with primary patency in 14 and secondary patency in the remaining patient. Clinical improvement was documented in all patients.

CONCLUSION

Primary stenting for occlusive disease isolated in the infrarenal aorta is relatively safe in selected patients with encouraging early follow-up results.

Advances in stent technology and drug-eluting stents

From an initially simple concept, vascular stents have evolved into highly specialized instruments, and are poised to develop into sophisticated drug-delivery systems. Although primary research has mostly targeted the coronary circulation, newer generation stents, deliverable almost anywhere, retarding neointimal hyperplasia and thrombosis, and promoting endothelial overgrowth, will offer the next approximation of true vascular healing. This, in turn,promises to promote less invasive, safer, and finally durable endovascular solutions to current surgical problems.

Primary Stent Placement for Infrarenal Aortic Stenosis: Immediate and Midterm Results

PURPOSE

To evaluate the safety and the long-term clinical and hemodynamic results of primary stent placement of atherosclerotic calcified stenosis of the infrarenal aorta.

MATERIAL AND METHODS

Between July 1996 and July 1999, 15 patients (nine male, si- female; mean age, 53.9 years) with symptomatic, calcified aortic stenosis were treated with primary stent placement. Patients underwent abdominal aortography and bilateral lower extremity arteriography. Follow-up was performed in all 15 patients. Technical success was defined as residual stenosis of less than 30% or a resting trans-systolic pressure gradient of less than 10 mm Hg after stent placement. Clinical patency was defined as the absence or improvement of symptoms after stent placement. Hemodynamic patency was defined as a normal triphasic Doppler waveform in the common femoral artery, an ankle-brachial index greater than 0.90, or the absence of a thigh-brachial pressure gradient at rest in either limb.

RESULTS

Technical success was achieved in 13 of 15 patients. The two patients considered to be technical failures had resting trans-systolic pressure gradients of 12 and 13 mm Hg, respectively, after stent placement. After the mean follow-up of 36 months, primary clinical and hemodynamic patency rates were 85% and the secondary hemodynamic patency rate was 100%. Two of five symptomatic recurrences during the 36-month follow-up period (range, 12-46 months) were a result of aortic restenosis and were treated with repeated percutaneous transluminal angioplasty. None of the patients required aortic surgery. Complications of the primary procedure included one puncture site infection, one pseudoaneurysm, and one distal embolization, which delayed discharge of three patients. There was no morbidity during the secondary interventions.

CONCLUSION

Primary stent placement as treatment of calcified infrarenal aortic stenosis proved to be safe and also provided durable long-term clinical improvement.

Primary Stenting of Focal Atherosclerotic Infrarenal Aortic Stenoses: Long-Term Results in 13 Patients and a Literature Review

We conducted this study to investigate the value of primary stent implantation for the endovascular treatment of focal atherosclerotic stenoses of the infrarenal abdominal aorta. The data of 13 patients with a localized complex infrarenal aortic stenosis who underwent primary stenting was retrospectively evaluated. The patients (6 females, 7 males) had a mean age of 57.3 +/- 9.1 years (mean +/- SD). In all patients, the aortic diameter was measured on CT sections, and a self-expanding endoprosthesis was primarily implanted followed by dilatation with single or double balloons. In 3 patients, additional distal stenoses were also endovascularly treated. The procedure was technically successful in all patients. No complications occurred except for 2 minor groin hematomas. During the 43 +/- 23 months (mean +/- SD) follow-up (range: 12-96 months), all stented aortic segments remained patent. Clinical patency was lost in 4 patients, which was due to atherosclerosis or restenosis distal to the aorta. In view of the excellent early and long-term results, we believe that primary stenting should be considered the first line treatment in properly selected patients with focal atherosclerotic infrarenal stenoses of the abdominal aorta.

Clinical efficacy of metal stents for the treatment of focal abdominal aortic stenosis

Seven patients (four women and three men) who underwent primary stenting of infrarenal abdominal aortic stenosis over a 4-year period are reported. The patients ranged between 44 and 77 years of age. All were referred for treatment of disabling claudication. Self-expanding stents with balloon assistance were used. A single complication, a retroperitoneal haematoma, requiring surgical intervention occurred in one patient. Patients had either complete resolution of symptoms (five of seven) or a substantial decrease in their claudication symptoms. Primary stenting is a safe and effective treatment for severe abdominal aortic stenosis.

Primary Endovascular Stent Placement for Focal Infrarenal Aortic Stenosis: Initial and Midterm Results

The objectives of this retrospective study were to determine the technical success, safety, and midterm results of primary stent placement of infrarenal aortic stenosis. Eight stenoses and one occlusion were treated with stent placement after balloon pre-dilation. Primary technical success was achieved in all patients. Five patients showed reperfusion or restored normal direction of flow of the inferior mesenteric artery. No complications occurred. There was a mean follow-up of 12 months (range, 3-20 months). Primary clinical and hemodynamic patency rates were 100% on follow-up examinations. Stent placement after balloon pre-dilation in properly selected patients with isolated infrarenal aortic stenosis is a promising durable treatment.

Endovascular Treatment of Isolated Atherosclerotic Stenosis of the Infrarenal Abdominal Aorta: Long-term Outcome

The purpose of this multicenter study was to assess the long-term outcome of endovascular treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta on the basis of clinical and ultrasound examination. Clinical, ultrasound, and angiographic findings from 36 women and 50 men (mean age, 53.2 years) treated for atherosclerotic stenosis of the infrarenal abdominal aorta were reviewed. Patients had claudication in 74 cases and rest pain in 4. Seven patients presented trophic manifestations and one had blue toe syndrome. Mean preoperative systolic index was 0.71. Mean diameter reduction was 77%. Circumferential calcification was partial in 36 cases (41%) and complete in 30 cases (35%). Percutaneous transluminal angioplasty was performed using the single-balloon technique in 60 cases and double-balloon technique in 26 cases. A stent was placed in 76 cases (88%) by necessity in 34% of cases (22 residual stenoses, 4 dissections). Completion angiographic findings were considered good in 82 cases (95%). The remaining four patients had residual stenosis with a diameter reduction >30%. One patient died during the immediate postoperative period from septicemia unrelated to treatment (early mortality, 1.2%). Aortic angioplasty was complicated by stent detachment from the angioplasty balloon in two patients, retroperitoneal hematoma in one, peripheral embolism in two, puncture-site hematoma in three, myocardial infarction in one, and thrombophlebitis of deep femoral artery in one patient (early morbidity, 9.3%). All patients underwent follow-up with clinical and hemodynamic evaluation (mean follow-up, 31 months). Actuarial survival at 3 years was 91%. Primary actuarial patency was 94% at 1 year, 89% at 3 years, and 77% at 5 years. Aortic restenosis occurred in seven patients and was treated by angioplasty in two, aortobifemoral bypass in four, and surveillance in one. Mean systolic index was 0.89. Statistical analysis of patency demonstrated no factor predictive of long-term complication. From the long-term follow-up findings in this study, we conclude that aortic angioplasty is a reliable minimally invasive technique for treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta.

Percutaneous endovascular treatment for stenoses and occlusions of infrarenal aorta and aortoiliac bifurcation: midterm results

OBJECTIVE

evaluation and comparison of the endovascular treatment of isolated aortic and aortoiliac atherosclerotic lesions (stenoses and occlusions).

METHODS

a percutaneous endovascular procedure was performed in 52 patients (38 men and 14 women) with a mean age of 52 years (range, 25-85 years). The baseline angiogram showed 35 aortic lesions (31 stenoses, 4 occlusions) and 17 aortoiliac lesions (14 stenoses, 3 occlusions). Percutaneous techniques used in this series included variable combinations of transluminal angioplasty and stenting. All stents placements were performed over-the-wire using the transfemoral route (most often bilateral approach). Clinical examination and Duplex-scan were performed at discharge, 1 month, 6 months, 12 months, and then yearly.

RESULTS

technical success was 100% for aortic and aortoiliac lesions. Angiographic success rates were comparable for aortic (91%) and aortoiliac (94%) lesions. No death occurred during or early after the endovascular intervention. Duplex-scan confirmed 100% patency rate at discharge. There was no significant difference between the aortic (94%) and aortoiliac (96%) groups regarding immediate clinical improvement. Mean follow-up was 34+/-31 months (range, 0-130 months). The cumulative primary patency rate at 36 months was 85% in the aortic group and 86% in the aortoiliac group. Clinical success, defined as a symptom-free status at the end of follow-up, was also similar in both groups.

CONCLUSION

endovascular treatment of isolated aortic lesions of the infra-renal aorta has favorable outcomes comparable to those of aortoiliac lesions.

Stenting for localised arterial stenoses in the aorto-iliac segment

OBJECTIVE

to determine complications and patency following angioplasty (PTA) and stenting of aorto-iliac stenoses.

SETTING

District General Hospital in U.K.

DESIGN

prospective observational study.

PATIENTS AND METHODS

between December 1994 and June 2000, 50 patients (38 men), median age 64 (41-89) years underwent aorto-iliac stenting. A total of 61 stents were placed. Indications were intermittent claudication in 38 and rest pain, ulceration or gangrene in 12. Sites stented were aorta 11, common iliac artery 32, external iliac artery 14, common and external iliac arteries two. Bilateral iliac procedures were carried out in nine. Two stents were used to correct residual stenoses after aortic stenting. Some 11 recurrent stenoses were treated. The other reasons for stenting were residual stenoses greater than 30% after PTA, tight calcified stenoses or when a stenosed iliac artery was being used as a donor prior to crossover or femoropopliteal bypass.

RESULTS

two immediate technical failures occurred due to malposition. Residual stenoses were corrected by PTA. Two further patients sustained minor complications. None of the aortic stents occluded through two required secondary procedures. Primary-assisted patency was thus 100% at three years. Primary patency following iliac stenting for claudication and critical ischaemia were 97% and 86% at three years respectively.

CONCLUSION

PTA and stenting of aorto-iliac stenoses can be safely achieved with durable results.

Infrarenal Aortic Stenosis: Value of Stent Placement after Percutaneous Transluminal Angioplasty Failure

PURPOSE

To evaluate the long-term clinical and hemodynamic effectiveness of aortic stent placement in cases of failure of intended infrarenal percutaneous transluminal aortic angioplasty (PTAA).

MATERIALS AND METHODS

Fifty-three patients who underwent technically successful PTAA were compared with 24 patients who underwent aortic stent placement because of PTAA failure (19 patients) or ulcerated lesions (five patients) that otherwise would have been treated surgically because of the embolization hazard associated with PTAA alone. Clinical patency was defined as the absence or improvement of symptoms after the intervention. Hemodynamic patency was defined as a normal Doppler waveform in the common femoral arteries, an ankle-brachial index greater than 0.95, or the absence of a thigh-brachial pressure gradient.

RESULTS

Three-year clinical and hemodynamic patency rates, respectively, were 85% and 79% for PTAA and 69% and 43% for aortic stent placement. No morbidity was encountered. With use of the Cox proportional hazards model, two significant risk factors were retained for restenosis: unchanged smoking habit (P =.04) and small dilatation diameter (P =.001). Aortic stent placement, performed in patients with a smaller aortic diameter (10.3 vs. 12.7 mm for PTAA), appeared to be a predictive factor for restenosis by using univariate analysis. By using the Cox proportional hazards model, however, the restenosis rates after PTAA and aortic stent placement were not significantly different.

CONCLUSION

When aortic diameter is taken into consideration, there is no evidence that clinical outcome after secondary aortic stent placement would be poorer than technically successful PTAA.

Primary stenting for chronic total occlusion of the infrarenal aorta

PURPOSE

To present a rare case of chronic total occlusion of the infrarenal aorta treated with a self-expanding endoluminal stent implanted without preliminary dilation.

METHODS AND RESULTS

A 68-year-old woman presented with severe bilateral buttock and thigh claudication. Angiography revealed total occlusion of the infrarenal abdominal aorta and relatively normal iliac vessels. Via a right groin puncture and a 9-F sheath, a 14-mm x 5-cm self-expanding Wallstent was deployed in the abdominal aorta and expanded with an angioplasty balloon. Completion angiography showed successful recanalization of the aorta with satisfactory distal flow. Palpable distal pulses were restored, and the patient's symptoms were alleviated. She remained asymptomatic until her death from a major stroke 11 months after aortic stent implantation.

CONCLUSIONS

Primary stenting may be considered a viable alternative to conventional surgery in selected patients with total infrarenal aortic occlusion.

Endoluminal treatment of acute aortoiliac thrombosis

A 55-year-old woman presented with an ulcerative stenosis of the distal abdominal aorta. She was scheduled to undergo percutaneous aortic balloon angioplasty the next day. Upon readmission, however, she complained of lower abdominal pain. A second abdominal angiogram revealed thrombosis of the infrarenal abdominal aorta and left common iliac artery. This was treated by means of simple transcatheter thrombus aspiration and thrombolysis, followed by stenting of the aorta.

Primary stenting in infrarenal aortic occlusive disease

PURPOSE

To evaluate the results of primary stenting in aortic occlusive disease.

METHODS

Thirty patients underwent primary stenting of focal concentric (n = 2) and complex aortic stenoses (n = 19), and aortic or aorto-iliac occlusions (n = 9). Sixteen patients underwent endovascular outflow procedures, three of whom also had distal open surgical reconstructions. Median follow-up was 16 months (range 1-60 months).

RESULTS

Guidewire crossing of two aorto-biiliac occlusions failed, resulting in a 93% (28/30) technical success. Major complications included one access hematoma, one myocardial infarction, one death (recurrent thromboembolism) in a patient with widespread malignancy, and one fatal hemorrhage during thrombolysis of distal emboli from a recanalized occluded iliac artery. One patient did not improve his symptoms, resulting in a 1-month clinical success of 83% (25/30). Following restenting the 26 stented survivors changed their clinical limb status to +3 (n = 17) and +2 (n = 9). During follow-up one symptomatic aortic restenosis occurred and was successfully restented.

CONCLUSIONS

Primary stenting of complex aortic stenoses and short occlusions is an attractive alternative to conventional surgery. Larger studies with longer follow-up and stratification of lesion morphology are warranted to define its role relative to balloon angioplasty. Stenting of aorto-biiliac occlusions is feasible but its role relative to bypass grafting remains to be defined.