Gustavo S. Oderich MDProfessor of SurgeryDirector of Endovascular TherapyDivision of Vascular and Endovascular Surgery

TIPS & TRICKS FOR ILIAC CTO LESIONS

SITE2015

FACULTY DISCLOSURE

• Consulting, CEC/ DSMB fees*Cook Medical Inc., WL Gore

• Research grants*Cook Medical Inc., WL Gore, Atrium Maquet

• Investigational, off-label use of devicesFenestrated, Branched Endografts, Atrium Maquet iCAST

• Speaker fees for non-CME conferences WL Gore, Endologix

* All consulting fees and grants paid to Mayo Clinic

SMA

R renal

L renal

Pre- Post-

• Peri-renal thrombus• Small hypoplastic aorta• Eccentric, cauliflour

calcification• Multiple failed

interventions

- Mortality: 1-4% - 5yr Patency >90%- Morbidity: 20-25%

< 1-5%

ROLE OF OPEN SURGERY

ENDOVASCULAR APPROACH IS WIDELY ACCEPTED FOR TASC D LESIONS

Sixt et al. J Endovasc Ther 2012

ILIAC STENTING

TASC A/BTASC C/D

TECHNICAL CONSIDERATIONS

• Choice of approachFemoral (ipsi/contra)Brachial/ radial

• Hybrid endarterectomy?• Adjuncts

Atherectomy (debulking)Reentrance catheters/IVUS

• Choice of balloons & stentCovered vs bare metal?Balloon vs self-expandable?

• Aortic stenting (CERAB)?

CHOICE OF APPROCH

• Retrograde approach- More convenient, but can be difficult to reentry

• Antegrade approach- Easier reentry, easier to stay central-luminal - Avoids dissections at the aortic bifurcation

• Contralateral femoral (up & over)- Less support but possible

• Brachial or radial- More support but cumbersome

ANTEGRADE UP & OVER APPROACH

V12Pulse t-PAMechanical thrombectomyPTA

Viabahn

V12

5Fr MPAcatheter

7Fr MPA Guide

7Fr Sheath7Fr Raabe sheath

7Fr MPA guide5Fr MPA catheter

HYBRID FEMORAL ENDARTERECTOMY

• Concomitant femoral bifurcation/ profunda disease

• Preference for bovine pericardial patch

• Before or after iliac stenting

Piazza et al. J Vasc Surg 2011

RESULTS OF FEMORAL ENDARTERECTOMY IN TASC D ILIAC LESIONS

ADJUNCTS FOR DIFFICULT ILIAC CTO

• IVUS• Reentrance catheters• Atherectomy

IVUS technology combined with reentry device

Dual channel device with IVUS Chromaflo

IVUS ASSISTED RECANALIZATION

• Percutaneous Right CFA• Left Femoral Endarterectomy• Retrograde left iliac SIA• Reentrance into distal aortic bifurcation• Bilateral Kissing CIA stenting•Left EIA stenting to the CFA

DEBULKING ATHERECTOMY WITH STENTING

BALLOONS & STENTS

• Long Balloons: Start with smaller, than the desired outcome

• Balloon Expandable Stents for Common iliac arteries and calcified external iliac arteries

• Self-Expanding Stents for tortuous external iliac arteries

Undersize

Do not rebuild the aortic bifurcation unnecessarily highSeparate aortic stenting then small overlap of iliac stents

KISSING STENTS

Too High Just right

• Inability to agressively dilate narrow aortic bifurcations

• Difference in stent configuration• Dead space around stents• Turbulence, stasis, re-circulation

around cells of stent and dead space

Neointimal hyperplasia Thrombus formation

J Vasc Interven Radiolo 2000

KISSING STENT FAILURE

CoveredEndovascular ReconstructionAorticBifurcation

Courtesy of Maquet Europe and Michel ReijnenP Goverde, M Reijnen, F Grimme

Adapted from Goverde, LINC 2013

Bare-Metal Stent Covered Stent

NEO AORTIC BIFURCATION

Potential advantages• PTFE layer

- Physical barrier- Less risk of embolization- Less risk of arterial disruption

• Radial force• Precise deployment• Varied configuration• Smaller profile

BALLOON EXPANDABLE COVERED STENT

1 stent = 4 shapes

12mm

20mm

12mm

18mm

16mm

Courtesy of Peter Goverde and Michel Reijnen

COVERED STENTAdvanta V12

Covered iliac stentsRate of binary stenosis

Author, year

Design n Stent type Covered Uncovered

Sabri, 2010 Retrospective 26 covered28 uncovered

Balloon-Expandable

1yr:92%2yr:92%

1yr:78%2yr:62%

Lammer, 2000

Prospective 61 Self-expandable

1yr:91% -

Wiesinger, 2005

Prospective 60 Self-expanding

1yr:91% -

Bosiers, 2007

Prospective 91 Balloon-Expandable

1yr:91%

Chang, 2008

Retrospective 71 covered122 uncovered

Mostly Self-Expandable

5yr:87% 5yr:53%

Mwipatayi,2011

RCT 83 covered84 uncovered

Balloon-Expandable

18mo:92% 18mo:75%

Grimme, 2012

Retrospective 69 primary46 re-intervention

Balloon-Expandable

P 1yr:95%P 2yr:90%R 1yr:88%R 2yr:82%

CONCLUSIONS

• Endovascular approach has been widely accepted as first option in many patients with TASC D iliac lesions

• Brachial approach may be needed in a minority of patients with difficult lesions

• Use of adjuncts (reentrance, atherectomy) may increase technical success

• Covered stents and CERAB needs to be considered to improve patency rates