Download - AORTO-ILIAC INTERVENTIONS
Aorto-iliac InterventionsLevent Oguzkurt, MD
Baskent University School of MedicineSection of Interventional Radiology
Adana, Turkey [email protected]
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…
Adana, Türkiye