Kissing Stents in Treatment of Chronic Total Occlusion (CTO) of Aortic Bifurcation

Transcription

1 Med. J. Cairo Univ., Vol. 84, No. 2, March: , Kissing Stents in Treatment of Chronic Total Occlusion (CTO) of Aortic Bifurcation HISHAM FATHI, M.Sc.; KARIM HOSNI, M.D.; KHALED HINDAWI, M.D.; OMAR EL-KASHEF, M.D. and AMR GAD, M.D. The Department of Vascular Surgery, Faculty of Medicine, Cairo University Abstract Background: Nowadays endovascular management of aortoiliac occlusive disease is considered the treatment of choice. Aortoiliac chronic total occlusion (AICTO) represents an endovascular challenge and technical aspects of revascularization of such lesions need to be addressed. Objectives: The aim of the work is to ensure the effective role of kissing stents in treatment of occlusive lesions of aortic bifurcation. Patients and Methods: This is a prospective study that includes 14 patients with atherosclerotic AICTO of aortic bifurcation treated in Kasr Al-Aini Hospital during the period from October 2012 to October Results: Technical success was achieved in 100% of cases. Kissing balloon angioplasty had been done in all cases for predilatation followed by kissing stenting. Conclusion: Routine stenting with the kissing technique remains the most safe and effective method for the treatment of aortic bifurcation CTO and represents a true endovascular alternative to surgery. Key Words: Endovascular Iliac Flush-kissing stent Predilatation. Introduction PERCUTANEOUS transluminal angioplasty (PTA) has proved to be an effective technique for the treatment of focal iliac artery stenoses [1]. The immediate technical success rate has improved significantly, up to 95%, especially with the use of adjunctive stent placement. The patency rates of 80% to 90% after 5 years that have been reported for short iliac stenoses are comparable to surgical results [2]. Complex iliac artery obstructions, particularly bilateral stenoses or total iliac artery occlusions, are usually treated with aortofemoral or aortobifemoral graft surgery. Although highly effective, Correspondence to: Dr. Hisham Fathi, The Department of Vascular Surgery, Faculty of Medicine, Cairo University these surgical interventions are associated with a substantial procedure-related risk for the patient. In a meta-analysis of studies published after 1975, the aggregated operative mortality rate was 3.3%, and the aggregated systemic morbidity rate was 8.3% [3]. The potential of contralateral embolism or contralateral iliac artery occlusion due to dislodgement of atherosclerotic or thrombotic material during unilateral PTA is the most important problem that can be prevented by kissing technique that was developed for bilateral simultaneous angioplasty of the common iliac arteries [3]. Aim of the work: The purpose of this study is to reasses the effective role of kissing stents in treatment of occlusive lesions of aortic bifurcation as regard technical success rate and long term patency. Patients and Methods This is a prospective study of 14 patients with symptomatic chronic atherosclerotic lower limb ischemia with isolated aortoiliac CTO of aortic bifurcation. It had been conducted at Kasr Al Ainy Hospital during the period from October 2012 to October Patient with iliac artery stenosis, acute embolism, thrombosis, dissection, arteritis, or those with an associated abdominal aortic aneurysm or associated other atherosclerotic lesion in lower limb arterial tree as femoropopliteal lesions are excluded. All patients are evaluated for their demographics, risk factors (diabetes, smoking, hypertention), clinical presentation, and indications of intervention. Preoperative evaluation: In addition to routine laboratory tests, all patients are evaluated by duplex and CT-angiography (CTA), and classified according to Trans Atlantic Inter-Society Consensus 173

2 174 Kissing Stents in Treatment of Chronic Total Occlusion (CTO) (TASC) classification into B (unilateral flush common iliac occlusion), and C (bilateral aortic bifurcation occlusion). Operative technique: All patients were adequately well hydrated before and after the procedure and prepared with a loading dose of 4 tablets of 75mg clopidogrel the day before the procedure. All cases were performed in the angiographic suite, in all cases we started with diagnostic angiography through contralateral femoral or brachial access according to CTA findings and then the lesions were approached through bilateral retrograde approach, or combined brachial and femoral approach. Heparin was given routinely after placement of a working sheath. In most cases, a hydrophilic stiff or soft-tip inch Glidewire (Terumo) combined with an angled catheter such as (Rim, or Burn catheter) has been used in negotiation of the lesion. Kissing balloon predilatation had been performed in all cases. The balloon diameter ranged between 6 and 7mm and balloon length ranged between 60mm and 100mm. Inflation pressure ranged between 8 and 12 atmosphere (atm) and inflation time ranged between 30 and 60 seconds. Routine kissing stenting performed in all patients. All stents were self expandable except in two cases we used balloon mounted stents (owing to the availability), stent size ranged between 6-8mm and length between mm. All patients had been discharged on 150mg aspirin and 75mg clopidogrel daily for 3 months. Follow-up: Clinical follow-up has been performed at 1 month, 6 months, 12 months by evaluation of symptoms as pain improvement or recurrence, and assessment of both lower limb pulsations, also aortoiliac duplex had been performed for 5 patients as clinical evaluation alone was not sufficient. Results Between October 2012 to October 2014, 14 patients with aortoiliac CTO underwent aortoiliac angioplasty and kissing stents. Of these, 10 cases; due to flush unilateral CIA occlusion (via combined brachial and retrograde femoral approach in 6 cases), and (via bilateral retrograde femoral approach in 4 cases), and bilateral lesion in 4 cases (two cases were managed by combined brachial and retrograde femoral approach, and other two cases are managed by bilateral retrograde femoral approach). 10 patients were males, and 4 patients were females. The 4 cases who had bilateral common iliac (CIA) lesions presented by bilateral lifestylealtering calf and thigh claudication (30%), and from patients who presented by flush unilateral CIA occlusion, 8 patients presented by unilateral lifestyle-altering claudication (57%), while 2 patients presented by rest pain (14%). According to the (TASC) classification, the 4 cases who had bilateral common iliac (CIA) (Fig. 1) lesions are classified as TASC type C. And from the 10 patients who presented by flush unilateral CIA occlusion, 8 cases were TASC B (Fig. 2a,b) and 2 cases were TASC C (Figs. 3,4). Of the 10 cases; of flush unilateral CIA occlusion 6 cases had been accessed via combined brachial and retrograde femoral approach (Fig. 5), and 4 cases had been accessed via bilateral retrograde femoral approach (Fig. 6), while in the 4 cases of bilateral lesion two cases had been managed by combined brachial and retrograde femoral approach, and the other two cases had been managed by bilateral retrograde femoral approach (Fig. 7a,b). All stents were self expandable except in two cases (owing to the avilability), stent size ranged between 6-8mm and length between mm. Technical success: Was 100% and was achieved by completion angiography and clinical assessment of distal pulsations. Morbidity: One patient developed brachial thrombosis after sheath removal that has been managed conservatively with anticoagulation with no further complications and 1 patient developed groin hematoma that had been also managed conservatively with hot fomentation. Mortality: No cases of mortality related to the intervention. Patency rate: Primary patency rate at 1,6,12 months was 100%. Fig. (1): Bilateral common iliac artery (CIA) occlusion.

3 Hisham Fa thi, et al. 175 (A) (B) Fig. (2): Unilateral flush right CIA occlusion (TASC B). Fig. (3) Fig. (4) Unilateral flush left CIA occlusion extending to external iliac artery (TASC C). Fig. (5): Steps of combined brachial and left retrograd femoral approach in unilateral left CIA occlusion.

4 176 Kissing Stents in Treatment of Chronic Total Occlusion (CTO) Fig. (6): Steps of combined bilateral retrograde femoral approach in unilateral right CIA occlusion. Fig. (7-A): Bilateral retrograde femoral approach in bilateral CIA occlusion (Before). Fig. (7-B): Bilateral retrograde femoral approach in bilateral CIA occlusion (After). Discussion Nowadays endovascular management of aortoiliac occlusive disease is considered the treatment of choice, as still represents an endovascular challenge and flush common iliac artery occlusive disease deserves extra considerations, as Concerns about access, how to tackle the lesion (from above or below), and the use of unilateral or kissing stents remain an important issues. Technical difficulties, such as the unavailability of suitable-sized high-pressure aortic balloons, and the relatively frequent occurrence of severe procedure-related complications, such as contralateral peripheral embolism in the case of conventional unilateral PTA, have been major drawbacks in the widespread use of interventional techniques in this location. Indeed, inflation of a single balloon in one common iliac artery close to the aortic bifurcation can cause compression of the contralateral

5 Hisham Fa thi, et al. 177 artery, resulting in relatively poor dilatation and risking contralateral embolization. To overcome these problems, the kissing balloon technique has been developed. In the performance of a simultaneous bilateral inflation of similar-sized balloons, the aortic bifurcation can be optimally dilated with minimizing the risk of plaque displacement and embolization. In the current study 14 patients with aortoiliac CTO underwent aortoiliac angioplasty and kissing stents. Of these, 10 cases; due to flush unilateral CIA occlusion (via combined brachial and retrograde femoral approach in 6 cases), and (via bilateral retrograde femoral approach in 4 cases), and bilateral lesion in 4 cases (two cases were managed by combined brachial and retrograde femoral approach, and other two cases are managed by bilateral retrograde femoral approach). Treiman et al. [4] preferred the contra-lateral approach to cross the lesion then all procedures as debulking and stent insertion were done from ipsilateral retrograde femoral access. Using only the retrograde ipsilateral femoral approach was the preferred access used by Brountzos et al. [5]. As it is short, straight and successful in 80% of cases, yet it has several disadvantages as it usually creates subintimal dissection which will be a problem in reentry as thickened aortic intima herald the reentry and also dissection may reach to renal and lumbar causing serious effects. So we advocate the use of two accesses even in unilateral disease either contra lateral femoral access or brachial access to do angiography and crossing the lesion and ipsilateral retrograde femoral used to insert the stent as the end near origin of iliac artery will be deployed 1 st allowing proper and precise insertion. Another advantage of using two accesses is performing angiography from the contra-lateral approach allowing good planning of work. With the presence of bilateral accesses it is easier to convert the procedure to kissing stents as required. It is also possible to use (wire loop) technique, which is passage of the wire from the contra-lateral side and crossover followed by crossing the lesion and picking up the wire from ipsilateral femoral sheath (may be facilitated by a snare but possible without) as this provides a secure passage of balloons & stents [6]. In the current study routine stenting had been used in all cases, even while treating unilateral iliac disease like studies performed by Uberoi et al. [7] and Poncyljucz et al. [8]. All cases includes predilatation as advocated in Schneider [9], Prestent dilatation has several advantages, as it makes the second femoral ipsilateral puncture easier, facilitates a smooth passage of the stent without any insult to the plaque, and allows a better view of dimensions of stent and balloon needed, also Pre-dilating the lesion is usually advisable if the residual lumen is severely restricted, as the stent may not expand sufficiently in order to allow placement of a post stent balloon angioplasty catheter [9]. In current study all stents were self expandable except in two cases (owing to the avilability), stent size ranged between 6-8mm and length between mm. In a study by Balzera et al. [10] they used self expandable (43%), balloon expandable (54%) and covered stents (3%) that had been used to seal perforations [10]. In current study kissing stents had been used in lesions that extend to aortic bifurcation either uni or bilateral as they were more effective in trapping the lesions that commonly occur at carina, also Brountzos et al. [5] recommended the use of simultaneous balloon dilatation at the origins of both CIAs even in the presence of unilateral lesion, to protect the contra lateral CIA from dissection or plaque dislodgement, with subsequent embolization. Because calcified lesions typically occurring at the aortic bifurcation are not amenable to balloon dilatation alone, kissing stents or aortic reconstruction technique is applied that was technically very successful [5]. Because lesions with irregular contours, calcification, and haziness may be especially prone to contra lateral displacement during unilateral dilation, kissing stents have been used to treat these complex plaques, even when they were predominantly unilateral like Mohamed et al. [11] that advocated kissing stents and stated that there were no long-term occlusions following kissing stents in a previously asymptomatic/non-diseased limb [11]. However, Smith et al. [12] in a recent retrospective review of patients underwent percutaneous treatment of unilateral CIA occlusive lesions, challenged this long established practice as 175 patient with unilateral ostial lesion of CIA were treated with PTA and stenting without contra-lateral protection: Only in two patients did the contralateral unprotected CIA developed mild stenosis, 17% and 24% respectively [12]. Lawrentschuk et al. [13] advocated also unilateral stenting and they noticed the following advantages: No extra balloon

6 178 Kissing Stents in Treatment of Chronic Total Occlusion (CTO) adding cost with potential arterial wall damage; no arterial compromise where the sum of two balloons exceeds the diameter of the adjacent aorta; and not having to perform a further catheterization. They concluded that the use of single balloon technique is a safe alternative to the kissing balloon technique for PTA of the proximal common iliac artery [13]. In the current study, technical success was achieved (evident by return of distal pulse and good refilling in completion angiography) in 100% of cases. This result is comparable to Leville et al. [14] (94%) and Schienert et al. [3] (90%). While results were higher than Greiner et al. [15] where technical success was achieved in 86% of their cases and this may be due to inclusion of more TASC D lesions (72% of their cases) adding more difficulties in crossing the lesion. Conclusion: Primary stent implantation with the kissing balloon technique is the most safe and effective method for the treatment of aortic bifurcation CTO for both uni or bilateral lesion and represents a true endovascular alternative to surgery, however it seems to be more costly. It is better to use two vascular accesses even in unilateral lesion to allow proper and precise insertion. References 1- TEGTMEYER C.J., HARTWELL G.D., SELBY J.B., ROBERTSON R., KRON I.L. and TRIBBLE C.G.: Results and complications of angioplasty in aortoiliac disease. Circulation, 83 (Suppl I): I-53 I-60, De VRIES S.O. and HUNINK M.G.: Results of aortic bifurcation grafts for aortoiliac occlusive disease: A metaanalysis. J. Vasc. Surg., 26: , SCHEINERT D., BRÄUNLICH S. and BIAMINO G.: Recanalization of the pelvic arteries. Euro PCR, , TREIMAN G.S.: Does stent placement improve the results of ineffective or complicated iliac artery angioplasty?. J. Vasc. Surg., 28: , BROUNTZOS E.N. and KELEKIS D.A.: Iliac artery angioplasty: Technique and results. Acta. Chir. Belg., 104: , GAINES P.A. and CUMBERLAND D.C.: Wire loop technique for angioplasty of total iliac artery occlusions. Radiology, 168: , UBEROI R. and TSETIS D.: Standaed for endovascular management of aortic occlusive disease. Cardiovasc. Intervent Radiol., 30: , PONCYLJUCZ W.F.A.: Primary stenting in the treatment of focal atherosclerotic abdominal aortic stenoses. Clin. Rad., 61: , SCHNEIDER P. A.: The Infrarenal Aorta, Aortic Bifurcation, and Iliac Arteries: Advice About Balloon Angioplasty and Stent Placement. In P.A. Schnieder, Endovascular skills Guidewire and Catheter Skills for Endovascular Surgery (3 rd ed.). New York, Informa Healthcare, BALZERA J.O., THALHAMMER A., KHAN V., ZAN- GOS S., VOGL T.J. and LEHNERT T.: Angioplasty of the pelvic and femoral arteries in PAOD: Results and review of the literature. Eur. J. Radiol., 75 (1): 48-56, MOHAMED F.S.B.: Outcome of kissing stents for aortoiliac atherosclerotic disease, including the effect on the non-diseased contralateral iliac limb. Cardiovasc. Intervent Radiol., 25: , SMITH J.C., WATKINS G.E., TAYLOR F.C., CARLSON L.A., KARST J.G. and SMITH D.C.: Angioplasty or stent placement in proximal common iliac artery: Is the protection of contralateral side necessary? J. Vasc. Interv. Radiol., 12: , LAWRENTSCHUK N., STARY D. and MILLER R.J.: Percutaneous Transluminal Angioplasty of Stenosis at the Common Iliac Artery Origin Using a Single Balloon Technique. EJVES Extra, 5: 55-56, LEVILLE C.D., KASHYAP V.S., CLAIR D.G., BENA J.F., LYDEN S.P., GREENBERG R.K., O'HARA P.J., SARAC T.P. and OURIEL K.: Endovascular management of iliac artery occlusions: Extending treatment to Trans- Atlantic Inter-Society Consensus class C and D patients. Vasc. Surg., 43: 32-9, GREINER A. DESSL A., KLEIN-WEIGEL P., NEU- HAUSER B., PERKMANN R., WADENBERGER P., et al.: Kissing stents for treatment of complex aortoiliac disease. Eur. J. Vasc. Endovasc. Surg., 26: , 2003.

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