Iliac Disease: Core Curriculum

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Iliac Disease:

CoreCurriculum

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Iliac DiseaseIliac Disease

Diagnosis Indications Technical Issues Treatment Options - PTA

- Surgical Complications Prognosis

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• Physical examination

– signs of peripheral ischemia

– distal embolization

– status of the peripheral pulses.

• Rest and exercise ABI

Iliac Disease : Initial AssessmentIliac Disease : Initial Assessment

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Iliac Disease: Diagnosis Noninvasive imaging modalities

• Pressure Gradients

• Duplex ultrasound (DUS) scans

• Magnetic resonance angiography (MRA)

• Computed tomography angiography (CTA)

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Pressure Gradients obtained during revascularization of iliac occlusion

A. Baseline gradient. B. Gradient after administration of nitroglycerine. C. Postballoon, significant resting gradient remains, evn without provocation. D. Gradient eliminated after stenting, demonstrating superior hemodynamic result.

Grossmans “Catheterization” 7th Ed. pg. 588-592.

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Iliac Disease: Duplex Ultrasound

• DUS has proved to be cost-effective and accurate for the detection of significant vascular stenoses and is therefore often used as the first diagnostic modality. 1, 2

• The poor monophasic duplex waveform at the common femoral artery is in itself an accurate marker of aortoiliac obstructive disease. Other waveforms are nondiagnostic for aortoiliac disease.3

1. Kohler et al Ann vasc surg 1990 (4) 280-2872. Visser et al Radiology 2000 (16) 67-773. Spronk et al J vasc surg 2005; 42(2): 236-242

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Three waveform “phases” consisting of a sharp systolic forward up rise and fall, an element of reverse flow during diastole, and an element of

forward flow during diastole

Triphasic

Two waveform “phases” consisting of a sharp systolic forward up rise and fall and an element

of reverse flow during diastole

One waveform “phase” with a sharp systolic rise, the lack of a reverse diastolic element, and a

fast diastolic fall, expected in arterial segments proximal to an obstruction

Sharp Monophasic

Biphasic

:

The loss of “sharpness” in systole, the lack of a reverse diastolic element, and a slow diastolic fall expected in arterial segments distal to an

obstruction

Poor (blunted) monophasic

Spronk et al J vasc surg 2005; 42(2): 236-242

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Iliac Disease: MR Angiography

• Enhanced MR angiography showed significant improvement (P < .001) compared with unenhanced MR angiography for diagnosis of clinically significant aortoiliac occlusive disease

Rapp et al Radiology 2005; 236: 71-78

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Iliac Disease: MR Angiography

Transverse reconstruction of a steady-state gadofosveset dataset showing stenoses

(arrows) in both right and left common iliac arteries.

Gadofosveset-enhanced MR angiography

Rapp et al Radiology 2005; 236: 71-78

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Iliac Disease: Computed Tomography Angiography

• CT angiographic examination is less invasive and less expensive than conventional angiography

• Improves resolution with decreased contrast load and acquisition time without increasing radiation exposure

Karcaaltincaba M, Foley D Cardiovasc Interv Rad2005; 28(2): 169-172

A

4-channel MDCT angiogram: Coronal curved planar reformatted images of the abdominal aorta and right iliac artery

Rubin et al 2000 Radiology 215: 63-70

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Morphological Stratification of Iliac Lesions

TASC Type A iliac lesions

• Single stenosis less than 3 cm of the CIA or EIA (unilateral/bilateral)

TASC Type B iliac lesions

• Single stenosis 3 to 10 cm in length, not extending

into the CFA

• Total of 2 stenosis less than 5 cm long in the CIA

and/or EIA and not extending into the CFA

• Unilateral CIA occlusion

ACC/AHA Guidelines

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Morphological Stratification of Iliac Lesions

TASC Type C iliac lesions

• Bilateral 5 to 10 cm long stenosis of the CIA and/or EIA, note extending into the CFA

• Unilateral EIA occlusion not extending into the CFA

• Unilateral EIA stenosis extending into the CFA

• Bilateral CIA occlusion

TASC Type D iliac lesions

• Diffuse, multiple unilateral stenosis involving the CIA, EIA and CFA (usually more than 10 cm long)

• Unilateral occlusion involving both the CIA and EIA• Bilateral EIA occlusions• Diffuse disease involving the aorta and both iliac

arteries• Iliac stenosis in a patient with an abdominal aortic

anuerysm or other lesion requiring aortic or iliac surgery

ACC/AHA Guidelines

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Indications for Revascularization

• Relief of symptomatic lower extremity ischemia, including claudication, rest pain, ulceration or gangrene, or embolization causing blue toe syndrome


• Restoration y/o preservation of inflow to the lower extremity in the setting of pre-existing or anticipated distal bypass

• Procurement of access to more proximal vascular beds for anticipated invasive procedures. Occasionally revascularization is indicated to rescue flow-limiting dissection complicating access for other invasive procedures

www.emedicine.com

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Iliac artery revascularization before cardiac surgery

• Significant bilateral disease in order to allow the intra-aortic balloon pump insertion

Specific Indications for Revascularization

Rigateli et al Internat J Cardiovasc Imag 2002; 22:305-310

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Iliac Disease: Angiography

• Diagnostic aortogram: Inflow and outflow of the target lesion

• Run-off angiography: Visualization of the lower extremity circulation

Transbrachial aortography documents a TransAtlantic Inter-Society Consensus class D iliac occlusion with right external iliac occlusion and complete occlusion of the left iliac system in a 46-year-old man with

disabling claudication Leville et al J Vasc Surg 2006; 43(1):32-39

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Iliac Disease: Technical Issues

Endovascular Access• Ipsilateral femoral artery• Contralateral femoral

artery• Brachial artery: In

patients with flush occlusions at the aortic bifurcation

Multiple access sites may be required for successful treatment:

• Bilateral femoral• Femoral/brachial

Leville et al J Vasc Surg 2006; 43(1):32-39

Endovascular recanalization was performed with a hydrophilic guidewire and catheter, and femoral access was obtained with ultrasound guidance

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Anticoagulation

• Aspirin (325 mg) once a day several days prior to the procedure

• Heparin (2500-5000 IU) after access has been obtained and prior to the intervention

Iliac Disease: Technical Issues

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Percutaneous transluminal angioplasty

(PTA) with or without implantation of a stent

is still considered as the gold standard in the

treatment of a peripheral lesion.

Iliac Artery Disease: Treatment

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• Endovascular treatment of iliac stenoses

– High technical success rates

– Low morbidity

• Iliac PTA/stenting

– High rates of patency

– Improvement in functional outcome for the individual patient

Interventional Management of Iliac LesionsInterventional Management of Iliac Lesions

Bosch et al Circulation 1999; 99:3155-3160

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Iliac Artery Disease: PTA

Iliac Angioplasty: metaanalysis of 2697 procedures before 199075% claudicants2 year primary patency of 81%5 year primary patency rate 75%

Short segment Iliac stenoses: PTA has 5 year 80-90% patency rate Pentacost Circulation 1994

Becker, Radiology 1989

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VA Randomized Study:

•Patients with limited disease suitable for PTA or surgery.•Excluding initial PTA failure rate of 15%, 3- year patency of 75% was equivalent in both arms Wilson SE, J Vasc Surg 1989

Swedish Study:

•Equivalent 1 year results Holm, Eur J Vasc Surgery 1991

Iliac Artery Disease: Surgical vs PTA Randomized Data

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Iliac Artery Disease: Stent vs PTA

Bosch 1997: meta-analysis of studies between 1990-1997• Stent placement lowered risk of long term failure by 39%

Kauffmann 1991: BE stent vs PTA• Randomized trial enrolled 131 patients• 2 year clinical patency:

• 89% after stent, • 70% after PTA.

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Contraindications (Relative) to Iliac Balloon Angioplasty

• Occlusion

• Long lesions (>5 cm)

• Aortoiliac aneurysm

• Atheroembolic disease

• Extensive bilateral aortoiliac disease

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Iliac Disease: Stent Placement

Balloon expandable stentBalloon expandable stent

• Greater radial force

Useful in extremely calcified stenoses and especially occlusions of the common iliac artery

• Allow greater precision for placement

Useful in Ostial Lesions

Self-expandable stentSelf-expandable stent

Used predominantly in :

• cross-over techniques and

tortuous vessels

• occlusions of the external

iliac artery

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JVIR 15:911;2004

Iliac Disease: Stent vs Stent

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Interventional Management of Iliac LesionsInterventional Management of Iliac Lesions

Type B Currently, endovascular treatment is more often used but insufficient evidence for recommendation

Type C Currently, surgery treatment is more often used but insufficient evidence for recommendation

Type AEndovascular treatment of choice

Type DSurgical treatment of choice

Dormandy JA et al J Vasc Surg 2000; 31:S1-S296

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• Complex long-segment and bilateral iliac occlusions can be safely treated via endovascular means with high rates of symptom resolution.

• Initial technical success, low morbidity, and mid-term durability are comparable to results with open reconstruction.

Interventional Management of Iliac Lesions


A liberal posture to open femoral artery reconstruction extends the ability to treat diffuse TASC-C and -D lesions via endovascular means.

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The Aortoiliac Kissing Stent Technique

• Reconstructs the aortic bifurcation by simultaneous deployment of bilateral CIA stents

• The kissing stent technique was developed to avoid complications during PTA of the aortic bifurcation, such as dissection, thrombosis, or significant residual stenosis. Primary placement of kissing stents has been shown to be safe and technically practicable, even in aortoiliac segments with complex atherosclerotic disease. 2

1. Greiner et al, Journal of Endovascular Therapy: Vol. 12, No. 6, pp. 696–703 2. Greiner et al Eur J Vasc Endovasc Surg 2003;26:161–165.

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• The proximal ends of the stents extend into the aorta such that two adjacent stent walls come into apposition for at least one centimeter in the native aorta

Not Stable • Stents positioned in this

manner reshape the aortic bifurcation more or less anatomically

The silhouettes of the right and left stents are marked with black and white lines, respectively. The proximal ends of the bilateral iliac stents extend into the aorta and overlap each other less than half their width

“Non-crossing” group

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“Crossing” Group

• The distal end of the stents slip over each other into a crossover position

Stable• The stents do not really

imitate the aortic bifurcation perfectly The silhouettes of the right and left stents are marked

with black and white lines, respectively. The proximal ends of the bilateral iliac stents extend into the aorta and overlap each other more than half of their radiologically verified width

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• Remove the vascular sheath when the activated clotting time (ACT) falls to <160 seconds

• Continue oral aspirin (325 mg/day) indefinitely / Clopidogrel?

• Perform ABIs and duplex scanning prior to hospital discharge

• Follow-up the patient with non - invasive testing to document continued patency.

Interventional Management of Iliac LesionsInterventional Management of Iliac LesionsPatient AftercarePatient Aftercare

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Iliac Disease: surgical Treatment

• Aortoiliac bypass• Aortofemoral bypass• PTA Vs surgery

– 157 iliac lesions was treated with PTA or bypass surgery

– No significant difference between PTA or surgery for death, amputations, or loss patency at 3 years

– No significant difference in the hemodynamic (ankle-brachial index) result of a successful procedure between the surgery group and the PTA group

Wilson et al J Vasc Surg 1989; 9: 1-9

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PTA Vs surgery

73%

82%

P=0.041

Bar graph of the 3-year event -free survival of PTA Vs surgery for iliac lesions


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Ankle- Barchial Index in Randomized Iliac Lesions

Baseline Post-treatment 3 year

PTA 0.50 ± 0.01 0.78 ± 0.04 0.80 ± 0.07

Surgery 0.50 ± 0.02 0.82 ± 0.03 0.78 ± 0.05


PTA Vs surgery

p, ns for all

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Iliac Disease: Complications Iliac PTA

Note – Numbers are percentages

Johnston KW Radiology 1993; 186(1):207-12

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Intraoperative complications• Dissection• Extravasation• Perforation • RupturePostoperative complications• At the access site: Pseudoaneurysm, atrioventricular

fistula• Distal embolization• Hematoma• Stent thrombosis • Systemic complications (<0.5%): Contrast or

atheroembolic induced renal failure, MI, CVA, death

Iliac Disease: Complications

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Iliac Disease: Perforation

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• Hypertension• Hypercholesterolemia• Poor tibial runoff• Clinical status: Critical limb ischemia• Smoking, Diabetes mellitus• Female gender• Vessel diameter < 8mm• Outflow status• Lack of antiplatelet regimen• Number of stents• Occlusion vs. stenosis

Iliac Disease: Iliac Disease: Predictors of long-term failurePredictors of long-term failure


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Iliac Disease: Favorable predictorsIliac Disease: Favorable predictors

• Short, focal lesion

• Large vessel size

• Common iliac (as opposed to external iliac)

• Single lesion ( as oppsosed to multiple serial lesions)

• Male gender

• Lesser Rutherford category (Claudication as opposed to critical limb ischemia)

• Presence of good runoff


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Ideal Iliac PTA Lesions

• Stenotic lesion

• Non-calcified

• Discrete (< 3cm)

• Patent run – off vessels (> 2)

• Non- diabetic patients


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Iliac Disease: Comparison of 3 year Results Iliac Disease: Comparison of 3 year Results Severity/Site/Variable 3 year Success

rate

Iliac Occlusion

1 site 66 % †

> 1 site 17 % †

Iliac Stenosis

Common iliac 68 % ‡

External iliac

Men 57 % †

Women 34 % †

Both common and external

Good runoff 73 % †

Poor runoff 30 % †

† Cox regression estimate ‡ Kaplan-Meier

Johnston KW Radiology 1993; 186(1):207-12

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Patency after iliac PTA by Clinical and Lesion variables

1 year % 3 year % 5 year %

ST/CL/GR 81 70 63

ST/LS/GR 65 48 38

OC/CL/PR 61 43 33

OC/LS/PR 56 17 10

CL, claudication; GR, good run-off; LS, limb-threatening ischemia; OC, occlusion; PR, poor run-off; ST, stenosis

Johnston et al Semin Vasc Surgery 1989; 3:117-22

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Patients Technique Follow-up Primary

Patency

Secondary Patency

Tegtmeyer 1991 200 PTA 7.5 yrs 85% 92%

Palmaz 1992 486 BE stent 2 yrs 92%

Strecker 1993 114 SE stent 3 yrs 95%

Henry 1995 184 BE stent 4 yrs 86%

Murphy 1995 83 BE stent 2 yrs 87.5%

Martin 1995 140 SE stent 2 yrs 71% 86%

Vorwerk 1996 109 SE stent 4 yrs 82% 91%

Schurmann 2002 110 SE stent 10 yrs 46% 55%(50%mortality)

Gaines 2005 116 BE stent 6 months 82.7&

Leville 2006 89 SE/BE stents

3 yrs 76 90

Iliac Artery Revascularization: Stenoses

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Long-term success

Primary and subsequent endovascular procedures for iliac lesions in 151 limbs

Kudo et al J Vasc Surg 2005; 42 (3):466.e1-466.e13

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Endovascular Treatment of Symptomatic Iliac Occlusions


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Iliac Disease:Outcomes

Kaplan-Meier curve estimates for primary patency, secondary patency, and limb salvage in all patients treated for iliac occlusion over 36 months. Primary patency was 76%, secondary patency was 90%, and limb salvage was 97% at 36 months with an SE less than 10%.


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Iliac Disease: Primary Patency

Kaplan-Meier curve estimates for primary patency in patients treated for iliac occlusion stratified by TransAtlantic Inter-Society Consensus (TASC) level over 36 months. No significant difference was found between groups. *SE exceeded 10%.


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Iliac Disease: Secondary Patency

Kaplan-Meier curve estimates for secondary patency in patients treated for iliac occlusion according to TransAtlantic Inter-Society Consensus (TASC) stratification. There was no significant difference between groups, and patency was greater than 90% for patients with type B and C iliac occlusions. *SE exceeded 10%.


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Patients Technique Follow-up Primary

Patency

Secondary

Patency

Vorwerk 1995 103 stents 4 yrs 78% 88%

Henry 2000 155 stents 8 yrs 73% 86%

Scheinert 2001 212 BE/SE/

covered

4 yrs 76% 85%

Mouanoutoua 2003

50 stents 2 yrs 93% 86%

Balzer

2005

43 Excimer laser BE/SE/ covered

4 yrs 86.1% 95.4%

Iliac Artery Revascularization: Occlusions

Iliac Disease: Core Curriculum

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