Endovascular and Hybrid Treatment of TASC C & D Aortoiliac Occlusive Disease
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1 Endovascular and Hybrid Treatment of TASC C & D Aortoiliac Occlusive Disease Arash Bornak, MD FACS Vascular & Endovascular Surgery University of Miami Miller School of Medicine
2 No disclosure
3 BACKGROUND Endovascular treatment of aortoiliac occlusive disease (AOD) has expanded rapidly in recent years Endovascular stent graft technology and progress in endovascular techniques have shown promising results in patency with much lower perioperative complications and faster recovery.
4 OBJECTIVE To report our experience and propose an algorithm for endovascular and hybrid revascularization in patients with TASC C and D AOD TASC C TASC D
5 TASC C & D AOD Aortic involvement No aortic involvement Endograft Stent graft Femoral involvement No femoral involvement Hybrid (HR) revascularization Endovascular iliac stent
6 TASC C & D AOD Aortic involvement No aortic involvement Endograft Stent graft Femoral involvement No femoral involvement Hybrid (HR) revascularization Endovascular iliac stent
7 Aortic involvement? TASC C TASC D
8 Aortic involvement? Endograft J Vasc Surg Feb;65(2):
9 J Vasc Surg Feb;65(2):
10 J Vasc Surg Feb;65(2):
11 J Vasc Surg Feb;65(2):
12 J Vasc Surg Feb;65(2):
13 RESULTS 10 high-risk patient (8 male and 2 female) 59 years (range, 50-69) 4 tissue loss, 6 rest pain 5 patients had aortic ectasia/aneurysm and common iliac artery occlusion (4 unilateral, 1 bilateral) 4 complete aortic occlusion 2 aortic stenosis with unilateral iliac occlusion and contralateral iliac artery stenosis J Vasc Surg Feb;65(2):
14 RESULTS 2 patients requiring brachial access 5 patients required additional iliac stents Operative time: 290 +/- 110 min ( min) Length of stay was 6.5 +/- 6 days (1-18 days) 5 patients required additional distal iliac stent placement 1 mid-aortic Palmaz stent J Vasc Surg Feb;65(2):
15 RESULTS 30-day complications: 1 expanding hematoma, 1 limb occlusion Follow-up 40 months (4-81 months) 80% primary patency (1 iliac stent stenosis at 4 months, 1 early limb thrombosis), 100% secondary patency No embolic event J Vasc Surg Feb;65(2):
16 TASC C & D AOD Aortic involvement No aortic involvement Endograft Stent graft Femoral involvement No femoral involvement Hybrid (HR) revascularization Endovascular iliac stent
17 Ann Vasc Surg May;29(4):839.e9-12. Stent graft
18 Ann Vasc Surg May;29(4):839.e9-12.
19 Ann Vasc Surg May;29(4):839.e9-12.
20 Ann Vasc Surg 2018; 47: 281.e1 281.e4
21 Ann Vasc Surg 2018; 47: 281.e1 281.e4
22 Ann Vasc Surg 2018; 47: 281.e1 281.e4
23 TASC C & D AOD Aortic involvement No aortic involvement Endograft Stent graft Femoral involvement No femoral involvement Hybrid (HR) revascularization Endovascular iliac stent
24 No aortic involvement TASC C TASC D
25 No Femoral artery involvement Endovascular repair (EVR) with iliac stenting Stent graft vs baremetal stent COBEST trial showed superiority of covered stents for TASC C & D AOD Self vs balloon expandable stent A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease. J Vasc Surg 2011;54: 1561e70.
26 TASC C & D AOD Aortic involvement No aortic involvement Endograft Stent graft Femoral involvement No femoral involvement Hybrid (HR) revascularization Endovascular iliac stent
27 Femoral artery involvement Hybrid revascularization combining femoral endarterectomy and iliac stenting
28 COVERED VS BAREMETAL ILIAC STENT *COBEST trial : 168 iliac arteries. Covered stent superiority in TASC C/D 18 months. **5 year primary patency 60%, assisted 97%, secondary 98% (covered 87% vs baremetal 53%). ***EVR 91% primary patency (22 pts, 8 HR) at 2 years vs ABF (21) 95%. *A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease. J Vasc Surg 2011;54: **Long-term results of combined common femoral endarterectomy and iliac stenting/stent grafting for occlusive disease. J Vasc Surg 2008;48: ***Increasing efficacy of endovascular recanalization with covered stent graft for TransAtlantic Inter-Society Consensus II D aortoiliac complex occlusion, J Vasc Surg 2015;62:
29 COVERED VS BAREMETAL ILIAC STENT Reinforces arterial wall Decreases risk of hemorrhage in ruptured severely calcified arteries Eliminates the risk of plaque prolapse and less ingrowth of hyperplastic tissue seen through bare-metal stents Risk: femoral repair site infection may involve the entire covered stent.
30 METHODS Retrospective review of TASC C/D AOD patients undergoing hybrid revascularization using primarily stent grafts ( ) Hemodynamic success (increase in the ipsilateral ABI> 0.1) Clinical success (improved symptoms of claudication, rest pain or wound healing) at 30-days. Mortality and major complications Repair patency
31 METHODS Pre-operative and post-operative monitoring 1)Pre-operative ABI/PVR, serial post-operative ABI/PVR 2)ABI decrease of 0.15 or recurrence of symptoms mandates further workup 3)Arterial US and PVR waveform pattern guides need for additional workup 4)Angiographic diagnosis (CTA vs catheter-based)
32 TECHNIQUE
33 TECHNIQUE
34 TECHNIQUE
35 RESULTS- Demographics Lesion Classification n=41 limbs (36 patients) Indication for Procedure 61% 39% TASC C TASC D 29% 27% Claudication Rest Pain Tissue Loss 44%
36 RESULTS- Demographics 63.4% had occlusion of the external iliac (EIA) and/or common iliac artery (CIA), including 14.6% concomitant ipsilateral EIA/CIA occlusion.
37 RESULTS- Demographics Stent Type (n=77) 14% Covered Bare Metal 86% 22.2% of patients had simultaneous adjunctive procedures: -5 infrainguinal bypasses -3 superficial femoral artery stents
38 RESULTS Operative time=340 +/-100min EBL=500 ( ) ml Hospital LOS=4(IQR 3-6)days Mean follow-up=23 (1-79) months
39 RESULTS-Complications 30 Day Mortality= 1 30-Day Complications
40 RESULTS Primary patency achieved in 85.4% Cumulative primary assisted & secondary patency in 92.6% 2 iliac stent thrombosis (2 & 22 months) 2 PTA (6 & 28 months) 1 explant infected stent 1femoral patch revision Overall Mortality = 34% Tissue loss only associated factor (57.1% vs 14.8% P=0.01)
41 CONCLUSIONS Majority of TASC C & D are amenable to HR or EVR Compared to traditional open procedure, HR & EVR for TASC C & D have : Low morbidity and fast post-operative recovery Comparable clinical outcomes Covered nature of stent grafts likely contributes to long term patency. Cost main constraint. Follow-up with serial ABI/PVR and arterial US is key for longterm patency. Current TASC recommendations may need to be revised
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