Endovascular management of chronic infrarenal aortic occlusion

Contralateral Snare Cannulation vs. Retrograde Gate Cannulation during Endovascular Aortic Repair in Difficult Iliac Artery Anatomy: A Single Center Experience

OBJECTIVE

Endovascular aneurysm repair is well established as the gold standard in treating abdominal aortic aneurysms. Generally, endovascular repair is performed using a bi or trimodular stent graft, requiring placement of a contralateral iliac limb. Deployment of the contralateral iliac limb requires retrograde gate cannulation of the endograft main body contralateral limb. This step represents the crucial point of a standard endovascular repair procedure and can become challenging, especially in the case of high iliac tortuosity. This study compares the procedural times between the retrograde gate cannulation and the contralateral snare cannulation to demonstrate the possibility of directly performing the contralateral snare cannulation in the case of a complex iliac anatomy assessed by the iliac tortuosity index.

METHODS

One hundred and forty-eight patients with infrarenal abdominal aortic aneurysms who underwent endovascular aneurysm repair from 2017 to 2022 were analyzed retrospectively. Cannulation times between retrograde gate cannulation and contralateral snare cannulation were compared for each degree of iliac tortuosity. The degree of iliac tortuosity was assessed through the iliac tortuosity index. Cannulation times were detected from inserting the wire into the introducer to passing through the radio-opaque gate markers.

RESULTS

The cannulation times were 2.94 min for the retrograde gate cannulation group and 3.15 min for the contralateral snare cannulation group, respectively, with no statistically significant differences (p = 0.33). Overall cannulation times were 2.98 min. For the iliac tortuosity index grade 0, the cannulation times were 2.71 min for the retrograde gate cannulation group and 3.85 min for the contralateral snare cannulation group, respectively, with a significant difference in favor of the retrograde gate cannulation group (p < 0.0001). For the iliac tortuosity index grade 1, the cannulation times were 2.74 min for the retrograde gate cannulation group and 2.8 min for the contralateral snare cannulation group, respectively, with no statistically significant differences (p = 0.63). Regarding the iliac tortuosity index grades 2 and 3, the cannulation times were 3.01 and 4.93 min for the retrograde gate cannulation group and 2.71 and 3.28 min for the contralateral snare cannulation group, respectively. The first group's times were significantly higher than the second group's (p = 0.01 and p = 0.0001).

CONCLUSIONS

In patients with infrarenal abdominal aortic aneurysms undergoing endovascular aortic repair, the gate cannulation times were significantly shorter for the contralateral snare cannulation method than the retrograde gate cannulation method in the iliac tortuosity index grades 2 and 3. Therefore, performing the contralateral snare cannulation method would be appropriate.

Comparison of Aortobifemoral Bypass and Endovascular Treatment for Chronic Infrarenal Abdominal Aortic Occlusion From the CHAOS (CHronic Abdominal Aortic Occlusion, ASian Multicenter) Registry

PURPOSE

To directly compare the clinical outcomes of aortobifemoral bypass surgery (ABF) and endovascular treatment (EVT) for chronic total occlusion (CTO) of the infrarenal abdominal aorta (IAA).

MATERIALS AND METHODS

In this retrospective, multicenter study, we used an international database of 436 patients who underwent revascularization for CTO of the IAA between 2007 and 2017 at 30 Asian cardiovascular centers. After excluding 52 patients who underwent axillobifemoral bypass surgery, 384 patients (139 ABFs and 245 EVTs) were included in the analysis. Propensity score-matched analysis was performed to compare clinical results in the periprocedural period and the long-term.

RESULTS

Propensity score matching extracted 88 pairs. Procedure time (ABF; 288 [240-345] minutes vs EVT; 159 [100-205] minutes, p<0.001) and length of hospital stay (17 [12-23] days vs 5 [4-13] days, p<0.001) were significantly shorter in the EVT group than in the ABF group, while the proportions of procedural success (98.9% versus 96.6%, p=0.620), complications (9.1% versus 12.3%, p=0.550), and mortality (2.3% versus 3.8%, p=1.000) were not different between the groups. At 1 months, ABI significantly increased more in the ABF group for both in a limb with the lower (0.56 versus 0.50, p=0.018) and the higher (0.49 versus 0.34, p=0.001) baseline ABI, while the change of the Rutherford category was not significantly different between the groups (p=0.590). At 5 years, compared with the EVT group, the ABF group had significantly better primary patency (89.4±4.3% versus 74.8±4.3%, p=0.035) and survival rates (86.9±4.5% versus 66.2±7.5%, p=0.007). However, there was no significant difference between the groups for secondary patency (100.0%±0.0% versus 93.5%±3.9%, p=0.160) and freedom from target lesion revascularization (TLR) (89.3±4.3% vs 77.3±7.3%, p=0.096).

CONCLUSION

Even with recent advancements in EVT, primary patency was still significantly better for ABF in CTO of the IAA. However, there was no difference between the groups in terms of secondary patency and freedom from TLR at 5 years. Furthermore, there was no difference in procedural success, complications, mortality, and improvement in the Rutherford classification during the periprocedural period, with significantly shorter procedure time and hospital stay in the EVT group.

Transbrachial Access Site Complications in Endovascular Interventions: A Systematic Review of the Literature

The transfemoral approach (TFA) or transradial approach (TRA) serves as the primary technique for most endovascular cases; however, the transbrachial (TBA) route is an alternative access site used when TFA and TRA are contraindicated. Although TBA has advantages over TRA, such as the ability to accommodate large guide catheters and devices, there is some apprehension in implementing TBA due to perceived access site complication rates. This article aims to glean the rate of access site complication from current literature.

Relevant studies were identified using the following search terms: ((access site complications) AND ((endovascular AND brachial) OR (percutaneous brachial access) OR (brachial))) OR (endovascular AND (percutaneous brachial access)); endovascular + brachial artery; endovascular + brachial artery + access site; and endovascular + brachial artery + access site complications. Articles published after 2008 addressing major complication rates from percutaneous TBA interventions were included.

Fifteen studies out of 992 total articles met the inclusion criteria. The major access site complication rate was 75/1,424 (5.27%). Patients who underwent hemostasis with a vascular closure device (VCD) had a major complication rate of 13/309 (4.21%) compared to a major complication rate of 65/1122 (5.79%) for patients who underwent hemostasis with manual compression (MC).

The major access site complication rate associated with TBA was 5.27%, which is relatively high compared to the complication rate in TFA or TRA. More prospective trials are needed to fully understand the access site complication rate in TBA interventions.

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.

Asymptomatic complete distal abdominal aortic occlusion with initial presentation of ruptured intracranial aneurysm

Aortoilliac occlusive disease is occlusive atherosclerosis disease involving the distal aorta and bifurcation of iliac arteries and it is a subtype of peripheral arterial disease. Total occlusion of the abdominal aorta is a rare occurrence with an incidence of 3% -8.5% among the aortoiliac occlusive disease patients. We present a case of a 53 years old patient with a background history of hypertension and ex intravenous drug abuser with negative retroviral screening status, with no previous complaints who was brought to the Emergency Department with sudden onset of altered sensorium and 1 episode of seizure. Computed tomography angiogram of the brain showed a ruptured anterior communicating artery aneurysm. Diagnostic conventional angiogram of the brain was planned; however, difficulty was encountered during bilateral femoral artery cannulation with the abrupt termination of bilateral common iliac arteries. Computed tomography angiogram of the abdomen showed incidental finding of total occlusion of the abdominal aorta. As a conclusion, total occlusion of abdominal aorta secondary to aortoiliac occlusive disease with an associated intracranial aneurysm is never reported in the literature to date. This case highlights the possibility of association in between these two conditions which may benefit from further research.

Management of Extensive Aorto-Iliac Disease: A Systematic Review and Meta-Analysis of 9319 Patients

PURPOSE

Despite advances in endovascular management of aorto-iliac occlusive disease (AIOD) including covered endovascular reconstruction of aortic bifurcation (CERAB) techniques, guidelines for management of symptomatic Trans-Atlantic Inter-Society Consensus (TASC II) type C/D lesions favour open surgical revascularisation. This meta-analysis investigates outcomes in patients with TASC II C/D lesions treated with open bypass procedures (OS), standard endovascular treatments (SEV) or CERAB.

METHODS

Multiple databases (MEDLINE, EMBASE and the Cochrane database) were searched to identify studies reporting endovascular and open treatment of extensive AIOD. Studies were independently assessed. Outcomes reported included 30-day morbidity/mortality and patency rates.

RESULTS

A total of 9319 patients undergoing intervention for extensive AIOD were identified from 66 studies. Median patient age was 64 years (n = 3204) for SEV, 58 years (n = 240) for CERAB and 59 years for OS (n = 5875). Pooled meta-analysis for 30-day morbidity in patients undergoing SEV, CERAB and OS was 9, 10 and 15%, respectively. Thirty-day mortality rate was 0.79, 0 and 3% in the SEV, CERAB and OS groups, respectively. In these groups, one-year primary and secondary patency was 90, 88, 96 and 96, 97, and 97% whilst three-year primary and secondary patency was 78, 82, 93 and 93, 97, 97% respectively. Five-year primary and secondary patency was 71 and 89% for SEV and 88 and 95% for OS, respectively. CERAB data were only available to 3 years.

CONCLUSIONS

This meta-analysis shows that thirty-day morbidity and mortality favours endovascular techniques. Primary patency remains better with OS in both early and midterms;; however, secondary patency is comparable in all groups. These findings suggest that SEV/CERAB may be considered as an alternative to OS in higher-risk patients.

The Outback Re-Entry Device. A Pictorial Review

The Outback™ Elite re-entry catheter (CORDIS, Cardinal Health, USA) is designed to facilitate placement and positioning of guidewires within the peripheral vasculature and allows for re-entry of a guidewire back into the true lumen of a vessel following a subintimal crossing of an arterial occlusion. The device was first introduced in 2005 and has become widely utilized in a variety of situations involving both arterial and venous interventions. This article aims to share our experiences with the Outback™ device and inform interventionalists of its utility and versatility.

Endovascular Revascularization for Aortoiliac Occlusive Disease

말초동맥질환은 하지혈관을 흔히 침범하는 폐쇄성 질환이다. 대동맥-장골동맥 부위에서 이를 치료하기 위한 재개통술은 전통적으로 수술적인 접근을 통한 우회술을 근간으로 하였으며, 최근에는 국소적이고 단순한 병변들을 위주로 혈관 내 접근법을 통한 치료법이 우선 권고되고 있다. 혈관 내 접근법은 그 최소침습적인 특성으로 인하여 수술의 위험성이 높은 환자에 대해서 활용하는 것이 일반적이었으나, 근래의 다양한 기법 및 기구의 발전으로 보다 다양한 질병 상태를 가진 환자에서 활용되어 수술적인 치료에 근접하는 결과가 보고되고 있다. 이 종설에서는 말초동맥 질환에 대한 진단 및 대동맥-장골동맥 부위의 혈관 내 재개통술에 활용되는 기법 및 기구들에 대해 살펴보고 그 역할에 대해 살펴보고자 한다.

Covered versus bare metal kissing stents for reconstruction of the aortic bifurcation in the ILIACS registry

OBJECTIVE

We compared the early and midterm outcomes of polytetrafluoroethylene covered stents (CSs) vs bare metal stents (BMSs) used in the kissing conformation for the reconstruction of the aortic bifurcation in aortoiliac obstructive disease.

METHODS

A multicenter cohort registry (2015-2019) collected data from 1306 patients who had undergone endovascular treatment of aortoiliac arterial obstructive disease. Only patients who had received bilateral iliac kissing stents for TransAtlantic Inter-Society Consensus (TASC) class C and D lesions were included in the present analysis. The 30-day outcomes, midterm primary patency, and limb salvage rates were compared between the CSs and BMSs in matched patient cohorts after propensity score matching. The follow-up results were analyzed using Kaplan-Meier curves. Cox proportional hazards models were used to identify the predictors of primary patency.

RESULTS

A total of 336 patients were treated with kissing stents, 201 with CSs (60%) and 135 with BMSs (40%). In the unmatched cohort, patients receiving CSs were more likely to have critical limb ischemia (41% vs 30%; P = .038), complex iliac lesions, such as TASC D (90% vs 56%; P < .01), and iliac occlusions (59% vs 44%; P < .01). After propensity score matching, 220 patients were selected (110 with CSs and 110 with BMSs), without differences in the clinical presentation (critical limb ischemia, 41% vs 33%; P = .167), or anatomic complexity (TASC D, 66% vs 60%, P = .21; iliac occlusion, 48% vs 49%, P = .89). The 30-day mortality was 0%. The early medical (unmatched, 5% vs 4%, P = 1.00; matched, 5% vs 4%, P = .75) and surgical (unmatched, 5% vs 5%, P = 1.00; matched, 5% vs 3%, P = .72) complication rates were similar between the CSs and BMSs. However, the CSs resulted in a lower risk of intraoperative iliac rupture (0% vs 3.5%; P = .013) and greater ankle-brachial index improvement (0.43 ± 0.22 vs 0.36 ± 0.24; P = .02). At 36 months, the overall primary patency (92% ± 7% vs 92% ± 8%; P = .38), secondary patency (98% ± 3% vs 98% ± 4%; P = .50), and limb salvage (93% ± 9% vs 97% ± 5%; P = .20) rates were similar. In cases of moderate to severe iliac calcification, the CSs showed better results in the matched cohort (100% vs 89% ± 9%; P = .048). On multivariate analysis, CS use (hazard ratio [HR], 1.67; P = .45) did not significantly affect primary patency, but older age (HR, 0.93; P = .03) and kissing stent diameter ≥8 mm (HR, 0.25; P = .03) were significantly associated.

CONCLUSIONS

In the present multicenter study, the use of kissing stents for the treatment of the aortic bifurcation provided good early and midterm results. CSs were preferred for more complex lesions, were protective from iliac rupture, and allowed for greater ankle-brachial index improvement. The 3-year patency rates were similar between the CSs and BMSs. However, CSs showed improved results in the case of moderate to severe calcification.

Endovascular management of aorto-iliac occlusive disease (Leriche syndrome)

BACKGROUND

Bypass grafting is the standard of care for chronic aorto-iliac occlusive disease (AIOD, aka Leriche Syndrome) but is associated with mortality rates of up to 25% if surgical re-intervention is necessary. Despite a recent shift towards an endovascular-first strategy for TransAtlantic InterSociety Consensus II ("TASC II") C and D lesions, reports from Leriche Syndrome are still limited.

PATIENTS AND METHODS

15 high-risk patients (11 male, 4 female), mean age of 60.6 years, with chronic aorto-iliac occlusive disease were retrospectively reviewed. Retrograde approaches via the bilateral femoral arteries for aortic occlusion less than 4 cm in length and/or antegrade fashion from the brachial artery for juxtarenal type lesions were made. For the latter, thrombolysis prior to angioplasty was also performed. Intraluminal or if necessary, subintimal angioplasty was performed with deployment of either bare metal stents or stentgrafts in a kissing-stent fashion.

RESULTS

A total of 28 iliac arteries and 14 occluded abdominal aorta were treated with 100% technical success, of which 25% success were achieved by using subintimal technique. Two minor complications occurred, including vascular rupture and distal emboli in one patient apiece, which were successfully managed via endovascular fashion. There were no complications of renal artery emboli. Primary and secondary patency rates at 1, 3 and 5 years were 92.3% and 100%; 83.9% and 100%; and 83.9% and 100%, respectively.

CONCLUSION

Endovascular therapy for chronic aorto-iliac occlusion has a high technical success rate, with good short- and mid-term primary and secondary patency rates and may provide a valid alternative to surgery for high-risk patients.

Comparative Long-term Outcomes of Patients with Aortoiliac Occlusive Disease Limited to Common Iliac Arteries Who Underwent Endarterectomy versus Bypass Grafting

BACKGROUND

The objective of this study was to compared outcomes of patients with aortoiliac occlusive disease (AIOD), limited to the common iliac artery, who underwent either aortoiliac thromboendarterectomy (AIE) or aortobiiliac bypass grafting (ABIB).

METHODS

A single-center, retrospective analysis of consecutive patients with AIOD who underwent either AIE or ABIB between 2010 and 2019 from a prospective database. Patients with disease extending to the external iliac or common femoral arteries were excluded. Data collected included demographics, cardiovascular risk factors, indication for surgery, preoperative and postoperative ankle brachial indexes (ABIs), estimated blood loss, major adverse events (MAEs), and long-term patency. The study end point was clinical success, defined as improvement in ABIs with resolution of symptoms. MAEs included return to the operating room for any reason, postoperative myocardial infarction, stroke, pneumonia, or venous thromboembolism.

RESULTS

Thirty-three patients, who met inclusion criteria, underwent repair for AIOD (AIE: 13; ABIB: 20) at our institution during this time. In both groups, there were more women than men (AIE: 11, ABIB: 10) with a mean age of 55 ± 7 years and 58 ± 6 years in the AIE and ABIB group, respectively. Indication for surgery included disabling claudication in 19 patients, ischemic rest pain in 13 patients, and tissue loss in one patient. No difference in cardiovascular risk factors or AIOD severity was noted between groups. Patients in the AIE group had slightly higher body mass index (30 ± 5 vs. 26 ± 6, P = 0.06). Two patients in each group required concomitant renal/mesenteric artery endarterectomy. One patient in the AIE group required bilateral femoral artery exposure and external iliac thrombectomy. MAEs (4 vs. 0) were higher in the ABIB group including, pneumonia in one patient, myocardial infarction in another, return to the operating room for evacuation of hematoma in the third and bypass graft thrombectomy with lower extremity angiography in the fourth patient. There were no differences in the intensive care unit or hospital length of stay between groups. Patients in both groups achieved return of normal ABI and complete resolution of their symptoms. At mean follow-up time of 43.4 ± 25.2 and 52.9 ± 35.4 months in the AIE and ABIB group, respectively, there was no symptomatic recurrence or need for reintervention while two patients in the ABIB group died of non-aortic-related issues.

CONCLUSIONS

Both procedures were safe, effective, and conferred high long-term primary patency with no need for reintervention in patients with AIOD limited to the common iliac arteries.

Clinical outcomes of endovascular treatment for chronic aortic occlusion: a retrospective multicentre registry: EVT for chronic aortic occlusion

AIMS

The aim of this study was to evaluate the clinical outcomes of endovascular treatment (EVT) for chronic aortic occlusion (CAO) using multicentre registry data.

METHODS AND RESULTS

From April 2003 to December 2015, data on 73 consecutive patients (55 men and 18 women; aged 70.7±12.2 years) who underwent EVT for CAO were collected retrospectively from 15 centres in Japan. The primary endpoint was the primary patency at 12 months after EVT. Secondary endpoints were procedural success and periprocedural complication rates. We analysed 67 patients who underwent complete endovascular revascularisation after 2007. Initial procedural success was achieved in 63 cases (94.0%). Complications occurred in three patients (4.5%) (stroke, n=1; distal embolism, n=1; access-site haematoma requiring blood transfusion, n=1). In patients after successful EVT (n=63), the primary and secondary patency rates at 12 months were 90.7% and 97.7%, respectively. During a mean follow-up period of 17.8 months, restenosis/re-occlusion was observed in eight patients (12.7%).

CONCLUSIONS

EVT for CAO could be performed safely with a high procedural success rate. The short-term clinical outcome was acceptable despite lesion complexity.

Five-Year Patency and its Predictors after Endovascular Therapy for Aortoiliac Occlusive Disease

Aim: Although current guidelines recommend surgical revascularization as the first-line therapy for chronic total occlusion of the abdominal aorta (Leriche syndrome), endovascular therapy (EVT) has been increasingly utilized because of the development of new technologies and techniques. EVT has demonstrated durable midterm outcomes for aortoiliac occlusive disease (AIOD). Nonetheless, little is known regarding their long-term outcomes and predictors of restenosis.

Methods: We retrospectively analyzed a multicenter database of 64 consecutive patients (age, 73 ± 10 years; 64% male; 22% critical limb ischemia) undergoing EVT for aortoiliac occlusive disease between September 2005 and March 2016. The outcome measures were primary and secondary patency, following EVT, calculated using the Kaplan–Meier method. Independent predictors associated with restenosis were assessed using Cox proportional hazard regression model.

Results: Technical success was achieved in 61 patients (95%). In total, 214 stents (192 self-expandable stents, 22 balloon-expandable stents) were implanted. During the follow-up of 33 ± 28 months, 11 patients experienced loss of patency. The primary patency rates were 88%, 70%, and 70% at 1, 3, and 5 years, respectively. The secondary patency rates were 98%, 87%, and 77% at 1, 3, and 5 years, respectively. In Cox regression analysis, E-Luminexx stent use (in 29 patients, 48%) was associated with restenosis [hazard ratio, 4.41, P = 0.038].

Conclusion: In this retrospective study, EVT for AIOD demonstrated favorable 5-year patency. E-Luminexx stent implantation was associated with restenosis in this population.

Revascularization of Chronic Total Occlusion of the Infrarenal Aorta in a Patient with Triple Vessel Disease: Report of a Case Treated by Endovascular Approach

Surgical management of advance aortoiliac occlusive disease is time-tested and a widely practiced strategy, particularly when there is significant coronary artery disease associated with aortoiliac occlusive disease. The technological advances in the field of percutaneous techniques have facilitated the use of nonsurgical endovascular alternatives for peripheral arterial disease in patients with significant comorbidities at high surgical risk, as illustrated in our case report. We report a case of chronic total occlusion of the aorta that was treated percutaneously with endovascular stenting. We also discuss the specific technique used in this procedure.

Endovascular Reconstruction for Chronic Infrarenal Aortoiliac Occlusive Disease

According to the 2007 TransAtlantic Inter-Society Consensus (TASC II) guidelines, surgery is the preferred treatment for extensive (TASC II type C and D) aortoiliac occlusive disease (AIOD). Recent studies, however, have shown that endovascular management can be an effective first-line treatment option for TASC II type C and D categories. While endovascular therapy is now commonly performed in patients with TASC II type D lesions, very few studies have investigated the feasibility and effectiveness of extending endovascular therapy to the most severe subcategory of TASC II D lesions, chronic infrarenal aortoiliac occlusion (CIAO). Herein, we present our technique for endovascular treatment of CIAO which relies on bidirectional subintimal aortoiliac dissection, wire snare for true lumen reentry, and combined balloon-expandable and self-expanding covered stent reconstruction of the aortic bifurcation and bilateral iliac arteries. This technique safely extends the reach of endovascular therapy to the most severe subcategory of TASC II D AIOD, CIAO. It is a viable minimally invasive alternative to aortobifemoral bypass surgery. Long-term follow-up of larger cohorts is needed to verify clinical efficacy and durability of therapy.

THE QUALITY OF LIFE IN PATIENTS WITH CORONARY HEART DISEASE

Occlusion of terminal aorta is mostly often caused by atherosclerosis and the development of lower limb ischemia requires prompt treatment. In addition to the open aortic surgery recanalization and stenting can also be used. The article presents the first experience of endovascular treatment in patients with good immediate and mid-term results. This method is suitable to use in patients with contraindications to general anesthesia.

Comparison of transfemoral vs transbrachial approach for angioplastic reconstruction of chronic total aortoiliac occlusion

The angioplasty of chronic total aortoiliac occlusion using transfemoral is controversial. From March 2014 to December 2015, four consecutive patients (4 males; mean age 58.2±6.8 years; age of range 51-65 years) underwent angioplasty and stenting of TASC-D occlusion. In all the cases, we failed to cross from femoral approach. On switching over to left brachial access, angioplasty was done successfully in all. There was no procedural site complication or clinical evidence cerebral thromboembolism. Self-expandable stents were implanted in all with adequate pre and post dilation. Complete revascularisation was achieved in two cases and in other two cases, the angioplasty to the left aortoiliac carina was staged. Therefore, it is better to avoid femoral approach as initial step to cross chronic TASC 2007 type D (chronic total aortoiliac occlusion or called extensive aortoiliac disease) because of failure to cross retrogradely due to subintimal course of guide wire leading to retrograde aortic dissection.

Endovascular treatment of TransAtlantic Inter-Society Consensus D aortoiliac occlusive disease using unibody bifurcated endografts

OBJECTIVE

Aortobifemoral bypass has been the gold standard treatment for extensive aortoiliac occlusive disease. Endovascular therapy and stenting of aortic and iliac occlusive lesions has proven to be efficacious, especially when dealing with short segment lesions. Endovascular treatment of TransAtlantic Inter-Society Consensus II (TASC) D aortoiliac occlusive lesions remains a challenge, but a valuable treatment option in poor surgical candidates. We present our operative technique and midterm results in treating TASC D aortoiliac occlusive disease using unibody bifurcated endografts.

METHODS

We performed a retrospective review of patients with TASC D aortoiliac occlusive disease who underwent transfemoral endovascular revascularization with the Endologix Powerlink unibody bifurcated endograft (Endologix, Irvine, Calif). Demographic data, operative details, and outcomes were collected. Paired t-tests were performed to compare preoperative and postoperative ankle brachial indexes.

RESULTS

Between March 2009 and July 2011, 10 high-risk patients (8 male and 2 female) for a traditional aortobifemoral bypass were treated using this endovascular technique. The mean age was 59 ± 6 years (range, 50-69 years). All patients presented with rest pain, and four with tissue loss. Technical success was 100%, with two patients requiring brachial access and eight patients requiring additional stent placement. Postoperatively, all patients reported clinical improvement with resolution of ischemic symptoms. Mean improvement ankle brachial index was 0.50 ± 0.08 (P = .028) and 0.50 ± 0.01 (P = .034) in the left and right legs, respectively. Mean follow-up time was 40 ± 24 months (range, 4-81 months). The primary and secondary patency rates were 80% and 100%, respectively. Complications requiring early reintervention occurred in two patients and included one expanding hematoma from the percutaneous access site and one acute iliac artery thrombosis. Additionally, one patient underwent repeat angioplasty/stenting for threatened endograft limbs at 4 months. One patient expired during follow-up from an unrelated cardiac cause 19 weeks postoperatively.

CONCLUSIONS

This series demonstrates that endovascular repair using a unibody bifurcated endograft for TASC D aortoiliac occlusive disease is feasible, effective, and has excellent midterm patency. It should be considered an effective treatment option when the disease process involves the aorta, in particular if the patient is surgically unfit for a traditional aortobifemoral bypass. The unibody configuration preserves the anatomic aortic bifurcation, which is particularly important in patients with peripheral occlusive disease who are deemed to undergo subsequent endovascular interventions.

Immediate hemodynamic changes after revascularization of complete infrarenal aortic occlusion: A classic issue revisited

Chronic total occlusion of the infrarenal aorta (CTOA) is a rare disease, characterized by severe impairment of limb perfusion. It is advocated that revascularization may improve survival rates, presumably due to improved cardiovascular performance; however no experimental or clinical data exist to identify a clear causative correlation and provide a relevant pathophysiologic background. Therefore we conducted a pilot study based on pulse wave analysis to detect the hemodynamic changes immediately after revascularization, in a group of six consecutive patients with CTOA. All patients were subjected to non-invasive measurements 1 day before surgery and at the end of the 1st postoperative month. Pulse wave analysis was performed noninvasively with a novel validated brachial cuff-based automatic oscillometric device. All patients had markedly preoperative high Augmentation Index (adjusted at heart rate 75 beats/min, AI@75). The AI@75 decreased from 46 ± 6.6 preoperatively to 24 ± 5.7 (p 0.0002). Wave reflection magnitude decreased from 72.3 ± 5.2% to 63 ± 6.7% (p 0.02). Cardiax index increased from 2.8 ± 1.2 to 3.4 ± 1.2l/min × 1/m(2) (p 0.41). Pulse wave velocity remained practically unchanged post-interventionally. These findings show that central aorta hemodynamics can be improved immediately following revascularization procedures in patients with complete occlusion of the entire length of the infrarenal aorta and can constitute the background of improved postoperative life-expectancy.

Korean Guidelines for Interventional Recanalization of Lower Extremity Arteries

Peripheral arterial occlusive disease caused by atherosclerosis can present with intermittent claudication or critical limb ischemia. Proper diagnosis and management is warranted to improve symptoms and salvage limbs. With the introduction of new techniques and dedicated materials, endovascular recanalization is widely performed for the treatment of peripheral arterial occlusive disease because it is less invasive than surgery. However, there are various opinions regarding the appropriate indications and procedure methods for interventional recanalization according to operator and institution in Korea. Therefore, we intend to provide evidence based guidelines for interventional recanalization by multidisciplinary consensus. These guidelines are the result of a close collaboration between physicians from many different areas of expertise including interventional radiology, interventional cardiology, and vascular surgery. The goal of these guidelines is to ensure better treatment, to serve as a guide to the clinician, and consequently, to contribute to public health care.

N, Lichtenfels E, Aerts N. Surgical treatment of chronic aortoiliac occlusion

BACKGROUND: Chronic aortoiliac occlusion (CAIO) is a significant cause of lower limb ischemia and is often found in young patients who smoke. OBJECTIVE: To review recent results achieved treating CAIO patients with open surgery. METHODS: From November 2011 to April 2014, 21 patients with CAIO were treated at the Santa Casa de Misericórdia, Porto Alegre, Brazil. Demographic data, comorbidities, clinical presentation and surgical results were analyzed. RESULTS: Eleven women and ten men were treated with direct aortic bypass (DAB; n=18) or with extra-anatomic bypass (EAD; n=3). Mean age was 53.7 ± 7.3 years (range: 43-79 years) and all patients smoked. Thirteen patients (62%) had critical ischemia. Six of the patients treated with DAB (33.4%) also required additional revascularization (3 renal and 3 femoropopliteal procedures). Perioperative mortality was zero. Four patients (22.2%) suffered transitory renal dysfunction, but only one patient (5.6%) required hemodialysis. Median follow-up time was 17 months (range: 2-29 months) and there was just one late death, from ischemic heart disease, 7 months after the surgery on the abdominal aorta. CONCLUSIONS: Aortic reconstruction is a safe method for treating patients with CAIO, with low perioperative morbidity and mortality rates.

Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication

Peripheral arterial disease (PAD) continues to grow in global prevalence and consumes an increasing amount of resources in the United States health care system. Overall rates of intervention for PAD have been rising steadily in recent years. Changing demographics, evolution of technologies, and an expanding database of outcomes studies are primary forces influencing clinical decision making in PAD. The management of PAD is multidisciplinary, involving primary care physicians and vascular specialists with varying expertise in diagnostic and treatment modalities. PAD represents a broad spectrum of disease from asymptomatic through severe limb ischemia. The Society for Vascular Surgery Lower Extremity Practice Guidelines committee reviewed the evidence supporting clinical care in the treatment of asymptomatic PAD and intermittent claudication (IC). The committee made specific practice recommendations using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system. There are limited Level I data available for many of the critical questions in the field, demonstrating the urgent need for comparative effectiveness research in PAD. Emphasis is placed on risk factor modification, medical therapies, and broader use of exercise programs to improve cardiovascular health and functional performance. Screening for PAD appears of unproven benefit at present. Revascularization for IC is an appropriate therapy for selected patients with disabling symptoms, after a careful risk-benefit analysis. Treatment should be individualized based on comorbid conditions, degree of functional impairment, and anatomic factors. Invasive treatments for IC should provide predictable functional improvements with reasonable durability. A minimum threshold of a >50% likelihood of sustained efficacy for at least 2 years is suggested as a benchmark. Anatomic patency (freedom from restenosis) is considered a prerequisite for sustained efficacy of revascularization in IC. Endovascular approaches are favored for most candidates with aortoiliac disease and for selected patients with femoropopliteal disease in whom anatomic durability is expected to meet this minimum threshold. Conversely, caution is warranted in the use of interventions for IC in anatomic settings where durability is limited (extensive calcification, small-caliber arteries, diffuse infrainguinal disease, poor runoff). Surgical bypass may be a preferred strategy in good-risk patients with these disease patterns or in those with prior endovascular failures. Common femoral artery disease should be treated surgically, and saphenous vein is the preferred conduit for infrainguinal bypass grafting. Patients who undergo invasive treatments for IC should be monitored regularly in a surveillance program to record subjective improvements, assess risk factors, optimize compliance with cardioprotective medications, and monitor hemodynamic and patency status.

Anatomical significance in aortoiliac occlusive disease

Aortoiliac occlusive disease is a subset of peripheral arterial disease involving an atheromatous occlusion of the infrarenal aorta, common iliac arteries, or both. The disease, as it is known today, was described by the French surgeon René Leriche as a thrombotic occlusion of the end of the aorta. Leriche successfully linked the anatomic location of the occlusion with a unique triad of symptoms, including claudication, impotence, and decreased peripheral pulses. The anatomical location of the atheromatous lesions also has a direct influence on classification of the disease, as well as choice of treatment modality. Considering its impact on diagnosis and treatment, we aimed to provide a detailed understanding of the anatomical structures involved in aortoiliac occlusive disease. Familiarity with these structures will aid the physician in interpretation of radiologic images and surgical planning.

Percutaneous Endovascular Recanalization of a Thrombosed Aortic Graft Limb with Stent Placement

Common practice in recanalization of a thrombosed prosthetic graft limb in an aortoiliac bypass focuses on balloon-catheter thrombectomy and angiographic exploration followed either by open surgical revision or endovascular management. This report describes the technique of percutaneous endovascular recanalization of an early thrombosed aortic graft limb with stent placement and subsequent restoration of patency and adequate limb perfusion, which remains patent after one year. Percutaneous intervention with stent placement and angioplasty for early graft limb recanalization avoids femoral incisions, and complications or morbidity associated with open surgery, while permitting rapid mobilization of the patient.

Transbrachial and femoral artery approach endovascular therapy for flush infrarenal aortic occlusion

OBJECTIVE

The purpose of this study is to report the efficacy of transbrachial and femoral artery approach endovascular therapy with catheter-directed thrombolysis (CDT) and adjunctive therapy for flush infrarenal aortic occlusion (FIAO).

MATERIALS AND METHODS

From March 2012 to December 2013, 11 consecutive patients (9 males; mean age 68 years; range 54-80 years) were submitted to endovascular therapy for FIAO. All patients were treated with CDT initially and then adjunctive endovascular treatments were performed to correct the underlying lesions.

RESULTS

Complete reconstruction of occluded aortoiliac arteries was successfully achieved in 81.8% (9/11) of patients. Left brachial and bilateral femoral arterial accesses were obtained in nine patients, and brachial and unilateral femoral in two patients. The residual lesions after CDT were corrected in nine patients and concomitant endovascular recanalization of superficial femoral artery was performed in two patients. Self-expandable stents were implanted in the all aortoiliac lesions with pre- and post-dilation. No renal or distal runoff embolization was seen during intraoperative angiography. Seven (7/9) patients with rest pain or tissue loss showed significant improvements in symptoms and two (2/9) patients with intermittent claudication gained an improved walking distance. The ABI rose significantly between pre- and post-procedure (0.84 ± 0.18 vs. 0.44 ± 0.13 on the right leg, p < .01; 0.89 ± 0.23 vs. 0.48 ± 0.16 on the left, p < .01).

CONCLUSIONS

Transbrachial and femoral artery approach endovascular therapy for FIAO offers an alternative to surgical reconstruction with immediate outcomes.

Successful revascularization to right coronary artery by percutaneous coronary intervention after endovascular therapy for leriche syndrome

A 69-year-old man with effort angina was admitted to our institution. Echocardiography showed poor left ventricular systolic function with akinesis of the anterior wall and severe hypokinesis of the inferior wall. We performed coronary angiography, which revealed two diseased vessels including chronic total occlusion in the left anterior descending artery and severe stenosis in the right coronary artery (RCA). In addition, aortography revealed aortoiliac occlusive disease known as Leriche syndrome. As the patient's symptom was stable, we first planned to perform endovascular therapy (EVT) for Leriche syndrome to make a route for intra-aortic balloon pumping. We prepared a bi-directional approach from bi-femoral arteries and a left brachial artery. The guidewire was passed through the occlusive area using the retrograde approach. The self-expanding stents were deployed by a kissing technique. At one week after EVT, a 6Fr sheath was inserted from the right radial artery and an intra-aortic balloon pump was successfully inserted through the right femoral artery for percutaneous coronary intervention (PCI) to the RCA. Two drug-eluting stents were successfully deployed to RCA after using an atherectomy device (rotablator). We reported the case as a successfully performed PCI to the RCA after EVT for Leriche syndrome.

Evaluation of four risk-scoring methods to predict long-term outcomes in patients undergoing aorto-bifemoral bypass for aorto-iliac occlusive disease

This study was done to determine the usefulness of the American Society of Anesthesiologists (ASA) classification, the comorbidity Charlson index unadjusted (CCIu),the comorbidity Charlson index adjusted by age (CCIa), and the Glasgow aneurysm score (GAS) for postoperative morbimortality and survival in patients treated with aorto-bifemoral bypass (AFB) for aorto-iliac occlusive disease (AIOD). A series of 278 patients who underwent AFB were restrospectively studied. For the CCIu, CCIa, ASA, and GAS, receiver operating characteristics curve analysis for prediction of morbidity showed area under the curves of 0.61 (p = 0.004), 0.59 (p = 0.026), 0.569 (p = 0.087), and 0.63 (p = 0.001), respectively. Additionally, univariate analysis showed that CCIa (p = 0.016) and GAS (p = 0.006) were associated significantly with an increased risk of developing complications. Furthermore, CCIa (p < 0.001) and GAS (p = 0.001) showed a significant association with survival. Finally, the variable age was related to morbidity (p = 0.004), mortality (p = 0.038), and survival (p < 0.001). The comorbididity and the age should be taken in account in clinical treatment decisions for patients with AIOD. The CCIa and GAS may play a role as predictive factors for postoperative morbidity and survival after AFB.

A successful retrograde re-entry at aorta using the Outback LTD catheter for a bilateral common iliac artery occlusion

The Outback LTD re-entry catheter system has become a valuable tool for peripheral intervention and it has been widely used for variable peripheral chronic total occlusion (CTO). However, its use in the setting of the aorta was restricted because of concerns of bleeding risks resulting from re-entry puncture or ballooning. This report presents a case of successful re-entry using the Outback LTD Re-Entry Catheter (Cordis, Bridgewater, New Jersy) at the aorta in a patient with bilateral common iliac artery occlusion.

A case achieved successful revascularization to severe ischemic coronary artery disease after endovascular recanalization with infrarenal aortic occlusion

An 80-year-old woman was admitted to our emergency department with ongoing dyspnea for 2 weeks. The patient was immediately intubated endotracheally because of the hypoxia with flush pulmonary edema. Electrocardiogram showed ST depression and echocardiogram showed hypokinesis of anterior left ventricular wall with poor systolic function. Also her cardiac enzymes were elevated, emergency coronary angiogram was performed from radial artery because both femoral arteries were not fully palpable. Coronary angiogram showed three vessels disease including chronic total occlusion of right coronary artery and left main bifurcation lesion. Also blood flow of left anterior descending coronary artery was delayed. Acute coronary syndrome was the cause of acute heart failure and revascularization was needed but aortography revealed total occlusion of infrarenal aorta. Patient was relatively hemodynamically stable; we planned treating total occlusion of infrarenal aorta with endovascular therapy to maintain a rout for cardiopulmonary support system. With bi-directional approach from both femoral artery and left brachial artery, occlusion site with heavy calcification was finally passed through by guide wire from retrograde approach. After pull-through technique, self-expanding nitinol stent was implanted after pre dilation with small balloon. Considering her EURO score, supposed perioperative mortality was high, percutaneous coronary intervention was performed. A 7 fr sheath was inserted from right femoral artery and intra-aortic balloon pump was inserted from left femoral artery. Sirolimus-eluting stent was implanted to left circumflex artery and also from ostium of left main to mid left anterior descending coronary artery after using an atherectomy device. After successful revascularization, patient became hemodynamically stable and weaning off the respirator was successful. Reporting case achieved successful revascularization to severe coronary artery disease after endovascular recanalization with infrarenal aortic occlusion.