Aorto-iliac InterventionsLevent Oguzkurt, MD

Baskent University School of MedicineSection of Interventional Radiology

Adana, Turkey loguzkurt@yahoo.com

Disclosure

I have the following potential conlict of interests to report

Consultant: BARD, Covidien

Surgical treatment: Aortoiliac bypass

• Patency – 82-91% at 5 years– 76-80% at 10 years

• Mortality: 3-4% at 30 days• Complications up to 21%

TASC ll

Type of obstructive lesions– Stenoses

• High technical success– Chronic occlusions

• Technical failures – Acute/chronic thrombosis

• Complications

Methods of treatment – PTA – Bare metal stents

– Self-expanding– Balloon-expanding

– Covered stents – Thrombectomy/thrombolysis

Objectives of endovascular treatment • High technical/clinical success• Low complications • High patency rates on short and long term

OBSTRUCTIONS INVOLVING THE AORTA

Aorto-iliac occlusion (TASC D) • 3%-8% of aortoiliac occlusive disease• Distal type/proximal (complete) type

• High technical failures • High complication rates • Requirement for thrombus removal• Low primary and secondary patency • 20 patients • Primary patency 66% @ 2 years

Yuan L, et al. J Vasc Surg 2014 59:663-8

Isolated aortic stenosis (TASC B) Localized form (normal iliacs) Diffuse form

Isolated aortic stenosis

De vries JPP, et al. J Vasc Surg 2004 39:427-34

• 69 patient • PTA with provisional stenting

(24 stent placement)• Technical success: 98%• No major complications• 5 year patency patency:

• Primary: 75%• Secondary patency: 96%

• PTA vs stent: No difference

Aortic stenosis with or without iliac artery involvementAdana Baskent Experience

• 40 patients (80% men); mean age, 59 years• 38 stenoses, 2 occlusions (iliac)• 18 patients aortic stenoses alone (localized/diffuse)• Mostly direct stenting (32 patients)• Technical success: 100%• Complications: 6/40 (15%)• Follow up: 1-72 months (median 24 months)• Patency at 3 years: 100% for aortic stenosis alone• Long term mortality higher in isolated aortic lesions

ILIAC ARTERY OBSTRUCTIONS

10 year patency after iliac a. stent placement• 110 patients (mean age 57 years)• 126 iliac lesion – 66 stenoses (PTA with provisional stent) – 60 occlusions (direct stent placement)

• Walstents• Primary/secondary patency (stent group) – 66%/79% @ 5 years – 46%/55% @ 10 years

• Survival – 83% after 5 years– 64% after 10 years

Schürmann K et al. Radiology 2002;224:731-8

Dutch iliac stent trial • RCT • 279 patients (mean age, 58 years)

– PTA with selective stenting 136 pts – Stent placement 143 pts

• Iliac stenosis or short (<5 cm) occlusion• PTA with selective stent placement group had better

improvement clinically• ABI, iliac patency, score for quality of life were similar• Patency at a follow up of 6.3 years (0.7-8.6 years)

– PTA with selective stent placement: 74%– Stent placement: 83%

• Stent+selective stent vs PTA alone: No difference Klein WEM, et al Radiology 2006 238:734-44

Primary stenting (vs PTA with provisional stenting)

• Direct stenting 110 patient• PTA with provisional stenting 41 patients

• Reduced perioperative complications (2.7% vs 24%)• Higher clinical success for longer stenosis (TASC C-D)• Similar clinical success on long term • Patency at 5 years – Similar for short stenosis – Higher with primary stenting for long segment occlusions

AbuRahma AF, J Vasc Surg 2007 46:965-70

STent versus AnGioplasty (STAG) • Multicenter RCT • Only technically successful cases were randomized• Patency: Presence of flow (at 1 and 2 years)• Planned recruitmen 144 patients• Trial halted after 118 patients

Goode SD, et al. Br J Surg 2013 100:1148-53

STent versus AnGioplasty (STAG)

Goode SD, et al. Br J Surg 2013 100:1148-53

• Multicenter RCT • Only technically successful cases were randomized• Patency: Presence of flow (at 1 and 2 years)• Planned recruitmen 144 patients• Trial halted after 118 patients

(COBEST trial)

• Multicenter RCT– Covered stents (n=83 iliacs)– Bare metal stents (n=85 iliacs)

• Longest follow up 18 months • Restenoses (CI: 0.15-0.82)

– 8 in covered stent group– 20 in BMS group

• Complete occlusion (CI: 0.07-1.09)

– 3 in covered stent group – 10 in BMS group

• Less re-intervention in the covered stent group

Bibombe P, et al. J Vasc Surg 2011 54:1561-70TASC C&D

Extensive iliac artery occlusions • TASC C and D• 19 studies, 1329 patients• Technical success: 86%-100%• Clinical improvement: 83%-100%• Length of hospitalization: 1-4.8

days• 5 year patency (8 studies)

– Primary patency: 60%-86%– Secondary patency: 80%-98%

• Mortality: 0-6.7%– 0% mortality in 12 studies– 1.2%-6.7% in 7 studies

• Morbidity: 3%-45%

• Most common complications: – Access site hematoma– Distal embolization– Arterial dissection – Pseudoaneurysm– Iliac artery or aortic rupture

Jongkind V J et al. Vasc Surg 2010 52:1376-83

Adana Baskent University experience• 127 chronic iliac a. occlusions in 118 patients• Direct stent placement in all• Technical success: 117/127 (92%)• Complications

– Major 22 pts (19%)– Minor 7 pts (6%)

• Mortality 1 patient• Primary patency at 5 years: 63%• Secondary patentcy at 5 years: 93%

Ozkan U, Oguzkurt L. Cardiovasc Interv Radiol 2010 33:18-24

90%

50%

Chronic iliac artery occlusions

127 iliac a. (2001-2008)

104 iliac a. (2008-2013)

P value

Number of patients 118 93

Technical success 92% 99% <0.01

Patency @3 years(primary/secondary)

63%/93% 60%/95% >0.05

ComplicationsMajorMinor

24%19%6%

15%9%6%

<0.01

*Published data Unpublished data

Influence of increased experience

*Ozkan U, Oguzkurt L. Cardiovasc Interv Radiol 2010 33:18-24

ENDOVASCULAR vs BYPASS

Open bypass Endovascular P

No of patients 3733 1625

Hospital stay (mean, days) 13 4 <0.001

Complications 18% 13% <0.001

30-day mortality 2.6% 0.7% <0.001

Primary patency @5 years 94.8% 80% <0.001

Secondary patency@5 years 95.7% 90% <0.001

RESTENOSIS

Risk factors for aortoiliac PTA/stent restenosis

• Occlusion length • Number of stents placed (occlusion length)• Small-diameter artery • Younger age (small artery?)• CLI (vs claudication)• Poor distal runoff• Stent in the external iliac artery • Female gender (small artery?)• Comorbidities (DM or chr. renal insufficiency)

• 102 recurrence out of 937 patients• Recurrent procedures:

– Higher morbidity during intervention – Lower clinical success– Lower 5-10 years patency

• Primary/secondary patency @ 10 years • 73%/90% (index procedure) • 66%/78% (recurrent procedure)

Davies MG, et al J Endovasc Ther 2011 18:169-180

Primary patency Secondary patency

• 84 iliac in-stent stenosis (BMS) – 61 stenoses– 23 occlusions

• Primary/secondary patency @ 5 years 38%/63%

Kropman RHJ et al EJVES, 2006; 32:634-8

PTA/stent for iliac in-stent restenosis

Cutting balloon for ISR• 14 patients • 9 focal, 4 diffuse, 1 extended outside the stent

margin • Patency 100% (mean follow up of 24 months)

with CDUS

Tsetis D, et al. J Endovasc Ther 2008 15(2):193-202

Direct stenting

• Reduced risk of rupture• Reduced distal embolism• Reduced overall

complications • Higher short term patency

PTA with provisional stenting

• Low short-term patency • Low/Similar long-term

patency • High complication • Nothing left behind

Direct stent placement recommended: – Aortoiliac junction (esp. balloon-expanding)– Heavy calcification (esp. balloon-expanding) – Iliac occlusions

Endovascular treatment of aortoiliac disease…..• High rate of technical success • Low morbidity, low mortality • Success has been limited by – Technical failures (occlusions) – Acute stent thrombosis (infrequent)– Restenosis on short and long term

• Stents/covered stents have higher short-term success• Drug-eluting balloons/stents are waited

Thank you…

loguzkurt@yahoo.com

Adana, Türkiye