ICVWG 09-1
Iliac Disease:
CoreCurriculum
ICVWG 09-2
Iliac DiseaseIliac Disease
Diagnosis Indications Technical Issues Treatment Options - PTA
- Surgical Complications Prognosis
ICVWG 09-3
• Physical examination
– signs of peripheral ischemia
– distal embolization
– status of the peripheral pulses.
• Rest and exercise ABI
Iliac Disease : Initial AssessmentIliac Disease : Initial Assessment
ICVWG 09-4
Iliac Disease: Diagnosis Noninvasive imaging modalities
• Pressure Gradients
• Duplex ultrasound (DUS) scans
• Magnetic resonance angiography (MRA)
• Computed tomography angiography (CTA)
ICVWG 09-5
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.
ICVWG 09-6
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
ICVWG 09-7
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
ICVWG 09-8
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
ICVWG 09-9
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
ICVWG 09-10
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
ICVWG 09-11
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
ICVWG 09-12
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
ICVWG 09-13
Iliac DiseaseIliac Disease
Diagnosis Indications Technical Issues Treatment Options - PTA
- Surgical Complications Prognosis
ICVWG 09-14
Indications for Revascularization
• Relief of symptomatic lower extremity ischemia, including claudication, rest pain, ulceration or gangrene, or embolization causing blue toe syndrome
Grossmans “Catheterization” 7th Ed. pg. 588-592.
• 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
ICVWG 09-15
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
ICVWG 09-16
Iliac DiseaseIliac Disease
Diagnosis Indications Technical Issues Treatment Options - PTA
- Surgical Complications Prognosis
ICVWG 09-17
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
ICVWG 09-18
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
ICVWG 09-19
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
ICVWG 09-20
Iliac DiseaseIliac Disease
Diagnosis Indications Technical Issues Treatment Options - PTA
- Surgical Complications Prognosis
ICVWG 09-21
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
ICVWG 09-22
• 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
ICVWG 09-23
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
ICVWG 09-24
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
ICVWG 09-25
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.
ICVWG 09-26
Contraindications (Relative) to Iliac Balloon Angioplasty
• Occlusion
• Long lesions (>5 cm)
• Aortoiliac aneurysm
• Atheroembolic disease
• Extensive bilateral aortoiliac disease
ICVWG 09-27
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
ICVWG 09-28
JVIR 15:911;2004
Iliac Disease: Stent vs Stent
ICVWG 09-29
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
ICVWG 09-30
• 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
Leville et al J Vasc Surg 2006; 43(1):32-39
A liberal posture to open femoral artery reconstruction extends the ability to treat diffuse TASC-C and -D lesions via endovascular means.
ICVWG 09-31
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.
ICVWG 09-32
• 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
ICVWG 09-33
“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
ICVWG 09-34
• 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
ICVWG 09-35
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
ICVWG 09-36
PTA Vs surgery
73%
82%
P=0.041
Bar graph of the 3-year event -free survival of PTA Vs surgery for iliac lesions
Wilson et al J Vasc Surg 1989; 9: 1-9
ICVWG 09-37
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
Wilson et al J Vasc Surg 1989; 9: 1-9
PTA Vs surgery
p, ns for all
ICVWG 09-38
Iliac DiseaseIliac Disease
Diagnosis Indications Technical Issues Treatment Options - PTA
- Surgical Complications Prognosis
ICVWG 09-39
Iliac Disease: Complications Iliac PTA
Note – Numbers are percentages
Johnston KW Radiology 1993; 186(1):207-12
ICVWG 09-40
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
ICVWG 09-41
Iliac Disease: Perforation
ICVWG 09-42
Iliac DiseaseIliac Disease
Diagnosis Indications Technical Issues Treatment Options - PTA
- Surgical Complications Prognosis
ICVWG 09-43
• 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
Grossmans “Catheterization” 7th Ed. pg. 588-592.
ICVWG 09-44
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
Grossmans “Catheterization” 7th Ed. pg. 588-592.
ICVWG 09-45
Ideal Iliac PTA Lesions
• Stenotic lesion
• Non-calcified
• Discrete (< 3cm)
• Patent run – off vessels (> 2)
• Non- diabetic patients
Grossmans “Catheterization” 7th Ed. pg. 588-592.
ICVWG 09-46
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
ICVWG 09-47
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
ICVWG 09-48
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
ICVWG 09-49
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
ICVWG 09-50
Endovascular Treatment of Symptomatic Iliac Occlusions
Leville et al J Vasc Surg 2006; 43(1):32-39
ICVWG 09-51
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%.
Leville et al J Vasc Surg 2006; 43(1):32-39
ICVWG 09-52
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%.
Leville et al J Vasc Surg 2006; 43(1):32-39
ICVWG 09-53
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%.
Leville et al J Vasc Surg 2006; 43(1):32-39
ICVWG 09-54
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
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