Endovascular Treatment Strategies in Aortoiliac Occlusion

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1 Cardiovasc Intervent Radiol (2009) 32: DOI /s CLINICAL INVESTIGATION Endovascular Treatment Strategies in Aortoiliac Occlusion Ugur Ozkan Æ Levent Oguzkurt Æ Fahri Tercan Æ Burcak Gumus Received: 21 October 2008 / Accepted: 16 January 2009 / Published online: 12 March 2009 Ó Springer Science+Business Media, LLC 2009 Abstract The aim of this study was to report our experience in endovascular treatment of total aortoiliac occlusion. Five patients who underwent endovascular recanalization procedures including manual aspiration thrombectomy, balloon angioplasty, and stent placement for total aortoiliac occlusion in a 4-year period were reviewed retrospectively. The mean age of patients was 51 years (range, 43 to 58 years). All patients had abdominal aorta and bilateral common iliac artery occlusion with or without external iliac artery occlusion. All patients either had a contraindication to surgery or refused it. Initial technical success was obtained in four of five (80%) patients. Endovascular techniques were successful in four patients who had good distal runoff and short-segment aortoiliac occlusion, but failed in a patient who had the worst distal runoff and long-segment aortoiliac occlusion. We observed two major complications, one of which was bilateral rupture of the common iliac arteries treated with covered stent placement. Another patient had extension of intra-aortic thrombus into the iliac stent after primary stenting. This was successfully treated with manual U. Ozkan L. Oguzkurt F. Tercan B. Gumus Department of Radiology, Baskent University Faculty of Medicine, Ankara, Turkey L. Oguzkurt loguzkurt@yahoo.com F. Tercan ftercan@yahoo.com B. Gumus burcakgumus73@yahoo.com U. Ozkan (&) Baskent Universitesi Adana Uygulama ve Arastırma Hastanesi, Dadaloglu Mahallesi 39, Sokak. 6, Adana 01250, Turkey radugur@yahoo.com aspiration thrombectomy. Aortic and iliac stents remained patent during the follow-up period (median, 18 months; range, 3 to 26 months) in four patients. Primary patency rates at 6, 12, and 24 months were all 80%. In conclusion, endovascular treatment can be an alternative for aortoiliac occlusion in selected patients. Short- to midterm follow-up so far is satisfactory. Removal of intra-aortic thrombus with manual aspiration thrombectomy before balloon angioplasty and/or stenting is possible and a good alternative to thrombolysis. Keywords Peripheral arterial disease Aortoiliac occlusion Endovascular treatment Angioplasty Thrombectomy Introduction Occlusion of the abdominal aorta can be complete, with involvement of the whole infrarenal segment, or partial, with occlusion of a short segment distally. Occlusion of both common iliac arteries usually coexists with aortic occlusion. The underlying pathology is usually atherosclerotic narrowing of the distal aorta and/or proximal iliac arteries. Thrombus frequently accumulates in the aorta, where there is slow and turbulent flow [1]. Aortobifemoral bypass graft placement has been the standard treatment of complete aortoiliac occlusion since the 1960s. Successful outcome of percutaneous endovascular treatment of isolated aortic stenosis or isolated iliac artery occlusion with percutaneous transluminal angioplasty (PTA) or stent placement encouraged the use of the same techniques in patients with complete or partial aortic occlusion with or without iliac artery involvement. In 1993, successful endovascular treatment of complete aortoiliac

2 418 U. Ozkan et al.: Endovascular Treatment Strategies in Aortoiliac Occlusion occlusion was first described by Diethrich [2] and Long et al. [3]; since then, there have been a few reports describing the endovascular treatment of complete aortoiliac occlusion. The first technique used for the treatment of aortoiliac occlusion was preliminary thrombolysis before PTA or stent deployment [2]. Then primary stenting without preliminary thrombolysis was tried, with success. Some authors recommend the latter technique because thrombolysis might cause added cost, time, and complications such as distal embolism [4 6]. The objectives of this study were to determine the viability and safety of aortoiliac recanalization and to assess endovascular treatment options for aortoiliac occlusion. Materials and Methods Between September 2004 and March 2008, five nonconsecutive patients (all male; age range, 43 to 58 years; mean age, 51 years) who underwent endovascular treatment for aortoiliac occlusion were reviewed retrospectively. Three patients had comorbidities making surgical treatment unlikely, and two patients refused to have operation for treatment. Demographic, procedural, and angiographic factors, complications, and outcome variables were defined according to reporting standards of the Society of Interventional Radiology (Table 1). All patients had chronic ischemic symptoms with a duration ranging from 7 months to 18 years. Four patients had severe intermittent claudication (category 3 according to the Rutherford classification) and one patient had rest pain (category 4). The pretreatment mean ankle-brachial index was All patients had TASC type D aortoiliac lesion diagnosed by computed tomography or magnetic resonance angiography and confirmed by digital subtraction angiography. All patients had a thorough examination of the distal runoff arteries, with angiography before and pressure measurements after the procedures. Distal runoff score was calculated according to the Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery), which categorizes scores as poor runoff (score [2.5 for bilateral procedures) and good runoff (score B2.5 for bilateral procedures) [7, 8]. Technical success was defined as\30% residual stenosis on angiography or \10 mm Hg pressure gradient on pressure measurement. Written informed consent was obtained from each patient after detailed explanation of risks and benefits of the procedure. All procedures were performed in the angiography unit under local anesthesia supplemented with intravenous sedation and analgesia using dormicum and fentanyl citrate. Heparin was administered intra-arterially at a dose of 5000 IU after placement of a vascular sheath. Access to the artery was obtained with bilateral common Table 1 Patients demographics, procedure details, outcomes, and follow-up Patient. Age Rutherford TASC Distal runoff Location of occlusions Intraaortic thrombus Technique Successful recanalization Major complication Patency on follow-up D 2.7 (poor) Aorta (6 cm), & EIA D 1 (good) Aorta (2 cm) & D 1 (good) Aorta (4 cm), & left EIA D 1 (good) Aorta (3 cm) & D 1 (good) Aorta (3 cm) & MAT of the aorta, aortic (single) & bilateral iliac stent deployment aorta & bilateral CIA with kissing stent technique aorta & iliac arteries with kissing stent technique MAT & balloon angioplasty of the aorta & bilateral CIA stenting aorta & iliac arteries with kissing stent technique Bilateral EIA ruptures Extension of thrombus into the stents in the CIA Occluded Patent Patent Patent Patent te: CIA common iliac artery, EIA external iliac artery, MAT manual aspiration thrombectomy

3 U. Ozkan et al.: Endovascular Treatment Strategies in Aortoiliac Occlusion 419 femoral artery puncture in four patients and right deep femoral and left common femoral artery puncture in one patient (patient 1). Aortic occlusion was below the inferior mesenteric artery (occluded aortic length ranging from 2 to 4 cm) in four patients and below the renal artery (6 cm) in another patient (patient 1). Associated iliac artery lesions are listed in Table 1. Luminal thrombus probably causing abdominal aorta occlusion on top of chronic aortoiliac lesions was detected in three patients. Both iliac and aortic occlusions were successfully crossed with a in. hydrophilic guidewire (Terumo Corp., Tokyo) by retrograde approach in four patients. Antegrade left brachial artery approach was required to negotiate the occlusion in one patient (patient 1) who had PTA or stent placement by femoral artery access. Manual aspiration thrombectomy (MAT) was performed with 7- to 9-Fr guiding catheters (Envoy; Cordis Corp., Miami, FL, USA) by femoral approach to eliminate thrombus after predilatation of the common iliac artery with a 5-mm balloon. After crossing of the aortoiliac occlusion, three different techniques were used for recanalization: (a) after removal of intra-aortic thrombus by MAT, mm selfexpandable Wallstent (Boston Scientific, Natick, MA, USA) for the aorta and mm self-expandable nitinol stent (Protege; ev3, MN, USA) deployment for common iliac arteries in one patient; (b) after removal of intra-aortic thrombus with MAT, balloon angioplasty of the underlying aortic stenosis with a balloon catheter and stent deployment for common iliac arteries in one patient (Fig. 1); and (c) primary stenting of the aorta and common iliac arteries (two 10-mm self-expandable nitinol stents) using the kissing technique in three patients. Additional selfexpandable stents (7 8 mm in diameter, mm in length) were placed to reconstruct the external iliac vessels in two patients. Self-expandable stents were dilated with same-size balloon catheters after deployments. Follow-up examinations were done at 1, 6, and 12 months and then every year, with clinical, hemodynamic, and radiological evaluations. Hemodynamic evaluation was provided by ankle brachial index measurement. Radiological evaluation was performed by color Doppler ultrasonography in all patients and contrast-enhanced computed tomography in three patients. Cumulative patency rates were calculated by SPSS statistical software using the life-table method. Fig. 1 A 52-year-old man with bilateral buttock and lower extremity c claudication. A Magnetic resonance angiography demonstrates distal abdominal aorta and bilateral common iliac artery occlusions. B Aortography shows removal of intra-aortic thrombus with manual aspiration thrombectomy using a 9-Fr guiding catheter under fluoroscopy guidance. C Control multislice computed tomography angiography (curved multiplanar reconstruction) 3 months after the procedure confirms the patency of the distal aorta and bilateral iliac artery stents

4 420 U. Ozkan et al.: Endovascular Treatment Strategies in Aortoiliac Occlusion Results Endovascular techniques were successful in restoring blood flow in four of five patients, with an initial technical success rate of 80%. Primary patency rate was 80% at 1 and 2 years. The only technical failure was a patient (patient 1) who had infrarenal (complete) occlusion of the abdominal aorta, bilateral common iliac and external iliac arteries, and right common and bilateral superficial femoral arteries. This patient had the worst distal runoff score among the five patients. This patient also had rupture of both common iliac arteries after balloon dilatation of the deployed stents, and two covered stents (Wallgraft; Boston Scientific) had to be deployed over the previously placed bare stents. Pressure measurement revealed a 25-mm Hg systolic pressure gradient across the covered stents, which could not be lowered with repeat balloon dilatations. Aortic thrombus was successfully eliminated with MAT in two patients before PTA and/or stenting. The burden of thrombus was small in another patient and we decided to do primary stenting. After deployment of the stent, thrombus sandwiched between the stent and the aortic wall slipped from its location into the stent and occluded the stent in the right common iliac artery. All thrombus in the stent was successfully cleared with MAT. Hospitalization time ranged from 1 to 6 days (four patients, 1 day; one patient with major complication, 6 days). Two patients had a major complication. Bilateral common iliac artery ruptures were encountered in one patient (patient 1), who had the longest duration of symptoms (18 years). Aortoiliac stents were occluded at 1- month follow-up in this patient. Reintervention was not considered because of significant comorbidities. The patient died of cardiac failure at 12 months of follow-up. Another major complication was thrombus extension into the deployed stent, which was treated by MAT in the same session. There was no minor complication. Distal embolism did not occur in any patient. Procedurerelated mortality was not encountered. The other four patients were alive at a follow-up period ranging from 3 to 26 months. ne of the patients who had successful endovascular treatment required another endovascular or surgical treatment on follow-up. Discussion Thrombosis of the aorta is usually the result of stasis of blood secondary to narrowing or occlusion of the aortoiliac junction and both iliac arteries. The atherosclerotic plaque alone does not necessarily occlude the aorta; thrombus frequently accumulates in narrowed aorta as a result of turbulence and slowing of flow [1]. The standard treatment of complete aortoiliac occlusion has been surgical bypass graft placement. However, alternatives to surgery may be preferable in patients who refuse surgery or have a high operative risk. Endovascular treatment of infrarenal aortic stenosis and isolated iliac artery occlusion has been recommended as a good alternative to surgical intervention since the 1980s. Although the use of intravascular stents has expanded the role of endovascular treatment technique in more extensive aortoiliac occlusive disease, reports on treatment of infrarenal aortic occlusion by endovascular approach are rare [9 13]. Endovascular treatment of infrarenal aortic lesions, especially infrarenal aortic occlusion, has only been reported in small case series, so that the safety and effectiveness of endovascular treatment have not been well established. Probable explanations for this may be difficulty of crossing chronic long-segment aortoiliac occlusion and fear of aortic rupture. Technical success of endovascular treatment has ranged from 78% to 100% in total aortoiliac occlusion [2, 6, 14, 15]. Martinez [2] and Diethrich [14] reported 100% technical success with preliminary thrombolysis before PTA and stenting in six and seven patients, respectively. Lagana and coworkers reported four successful recanalizations in five patients (80%), of whom three had long-segment and two had shortsegment abdominal aorta occlusion. One unsuccessful recanalization was reported in a patient who had complete occlusion of the infrarenal abdominal aorta, both common and external iliac arteries [15]. The lowest technical success rate (78%) was reported in nine patients by Nyman et al. The authors explained the low rate of success by the fact that no attempt was made to approach from a brachial access site in two patients with aortobi-iliac occlusions, which later proved to be successful in a patient with similar lesions [6]. In our patient population, four patients (80%) who had good distal runoff and relatively short-segment aortoiliac occlusion were successfully treated by the endovascular approach, whereas one patient who had longsegment aortoiliac occlusion and poor distal runoff was not. The technique first used to treat complete aortoiliac occlusion was preliminary thrombolysis for eliminating intra-aortic thrombus before PTA or stent deployment. Diethrich reported treatment of seven patients with complete abdominal aortic occlusion with urokinase infusion before stent placement. They described two embolic complications related to the thrombolytic infusion [2]. Thus, some authors have recently recommended primary stent deployment without preliminary thrombolysis, which may cause increased cost, time, and complications such as distal embolism [4, 5]. However, Lagana and coworkers treated complete aortoiliac occlusion in 5 patients, partial aortoiliac occlusion in 3 patients, and severe aortic stenosis in 11 patients with primary stent placement. They observed distal

5 U. Ozkan et al.: Endovascular Treatment Strategies in Aortoiliac Occlusion 421 embolism in two cases and mild renal failure due to microembolism into the renal artery in another case. It seems that thrombolysis can cause and avoid complications and its best use is still unclear. We experienced a complication related to primary stenting, extension of intra-aortic thrombus into the iliac stent after primary stent placement in one patient. This thrombus was cleared completely with MAT. MAT has been successfully used in different arterial and venous thromboembolic occlusions such as deep venous thrombosis, acute arterial occlusion, and pulmonary thromboembolism [16 18]. Its use in the aortic occlusion has not been reported before. The advantages of MAT over thrombolysis are shorter hospitalization and recovery times and reduced cost or complications, such as distal embolism and bleeding related to thrombolytic agents. The two cases in our patient group showed that MAT can clear the entire thrombus, obviating the need for thrombolytic administration, and can be a viable alternative to thrombolysis. Aortouni-iliac stenting with a femorofemoral crossover graft is another alternative combined management of extensive aortoiliac occlusion [19, 20]. Whitbread and coworkers treated four patients with aortobi-iliac occlusion using primary stent placement including three aortouniiliac endovascular reconstructions combined with femorofemoral crossover grafting or aortobi-iliac stenting. They concluded that aortoiliac stenting with or without adjuvant extra-anatomic crossover graft offers primary patency rates comparable to those for aortobifemoral grafting while avoiding major abdominal operation or risk of iatrogenic erectile impotence in younger patients. As new stent designs become available, bilateral aortoiliac stenting may become a good alternative for aortoiliac occlusion [20]. In conclusion, our results and review of the available literature indicate that endovascular techniques can be used successfully in treatment of aortoiliac occlusion in selected patients. The method seems to be more effective in short occlusion of the aorta than in total infrarenal aortic occlusion. Removal of intra-aortic thrombus by MAT before PTA and/or stenting is possible and a good alternative to thrombolysis. References 1. Hallisey MJ, Meranze SG (1997) The abnormal abdominal aorta: arteriosclerosis and other diseases. In: Baum S (ed) Abrams angiography, vol II, 4th edn. Little, Brown, Philadelphia, pp Diethrich EB (1993) Endovascular techniques for abdominal aortic occlusions. Int Angiol 12: Long AL, Gaux JC, Raynaud AC et al (1993) Infrarenal aortic stents: initial clinical experience and angiographic follow-up. CardioVasc Interv Radiol 16: Ballard JL, Taylor FC, Sparks SR, Killeen JD (1995) Stenting without thrombolysis for aortoiliac occlusive disease: experience in 14 high-risk patients. Ann Vasc Surg 9: Badiola CM, Scappaticci F, Scoppetta DJ (1999) Primary stenting in complete aortic occlusion. AJR Am J Roentgenol 172: Nyman U, Uher P, Lindh M, Lindblad B, Ivancev K (2000) Primary stenting in infrarenal aortic occlusive disease. Cardio- Vasc Interv Radiol 23: Ahn SS, Rutherford RB, Becker GJ et al (1993) Reporting standards for lower extremity arterial endovascular procedures. Society for Vascular Surgery/International Society for Cardiovascular Surgery. J Vasc Surg 17(6): Rutherford RB, Baker JD, Ernst C et al (1997) Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 26(3): Stoeckelhuber BM, Stoeckelhuber M, Gellissen J, Kueffer G (2006) Primary endovascular stent placement for focal infrarenal aortic stenosis: long-term results. J Vasc Interv Radiol 17(7): Yilmaz S, Sindel T, Yeğin A, Erdoğan A, Lüleci E (2004) Primary stenting of focal atherosclerotic infrarenal aortic stenoses: long-term results in 13 patients and a literature review. Cardio- Vasc Interv Radiol 27(2): Gandini R, Fabiano S, Chiocchi M, Chiappa R, Simonetti G (2008) Percutaneous treatment in iliac artery occlusion: longterm results. CardioVasc Interv Radiol 31(6): Uberoi R, Tsetis D (2007) Standards for the endovascular management of aortic occlusive disease. CardioVasc Interv Radiol 30(5): Houston JG, Bhat R, Ross R, Stonebridge PA (2007) Long-term results after placement of aortic bifurcation self-expanding stents: 10 year mortality, stent restenosis, and distal disease progression. CardioVasc Interv Radiol 30(1): Martinez R, Rodriguez-Lopez J, Diethrich EB (1997) Stenting for abdominal aortic occlusive disease. Long-term results. Tex Heart Inst J 24(1): Laganà D, Carrafiello G, Mangini M et al (2006) Endovascular treatment of steno-occlusions of the infrarenal abdominal aorta. Radiol Med (Torino) 111(7): Oguzkurt L, Tercan F, Ozkan U (2008) Manual aspiration thrombectomy with stent placement: rapid and effective treatment for phlegmasia cerulea dolens with impending venous gangrene. CardioVasc Interv Radiol 31(1): Tajima H, Murata S, Kumazaki T et al (2004) Manual aspiration thrombectomy with a standard PTCA guiding catheter for treatment of acute massive pulmonary thromboembolism. Radiat Med 22(3): Xu GF, Suh DC, Choi CG et al (2005) Aspiration thrombectomy of acute complete carotid bulb occlusion. J Vasc Interv Radiol 16(4): Marin ML, Veith FJ, Cynamon J et al (1994) Transfemoral endovascular stented graft treatment of aortoiliac and femoropopliteal occlusive disease for limb salvage. Am J Surg 168(2): Whitbread T, Cleveland TJ, Beard JD, Gaines PA (1998) The treatment of aortoiliac occlusions by endovascular stenting with or without adjuvant femorofemoral crossover grafting. Eur J Vasc Endovasc Surg 15(2):