Role of endovascular therapy in TASC II C & D inflow disease Per the TASC II Document: Surgery is the treatment of choice for type D lesions Aortoiliac occlusive disease Bala Ramanan, MBBS 1 st year vascular surgery fellow Surgery is the preferred treatment for good-risk patients with type C lesions. The patient's co-morbidities, fully informed patient preference and the local operator's long-term success rates must be considered when making treatment recommendations for type C lesions Since the introduction of TASC guidelines for the treatment of aortoiliac occlusive disease, there has been tremendous advancement in endovascular techniques Data available since the TASC II guidelines were published Case Presentation 63 year old female. Life style limiting left calf claudication for one year. CT angiogram at outside hospital demonstrated left diffuse common and external iliac disease. Unsuccessful anterograde and retrograde attempts at an outside hospital 2 weeks prior to presentation at UCSF. Review articles and several studies have shown the feasibility of endovascular therapy for TASC II C and D lesions. Primary patency rate is lower for endovascular therapy compared to surgery (60-86%) at 5 years. Secondary patency rate is 80-98% for endovascular therapy at 5 years. PMH: HTN, dyslipidemia, CAD s/p MI 2006 and subsequent PCI-stable from cardiac standpoint for surgery. Medications: Tylenol with codeine, alprazolam, aspirin, carvedilol, metformin, multivitamin, simvastatin. SH: 99 pack-year smoking history, stopped 2 months prior to presentation, nondrinker. 1
Physical Examination Abdomen- soft, non tender. Aorta not palpable. Left groin incision was not completely healed. No sign of infection. Pulse exam: R side lower extremity pulses were normal. Left lower extremity pulses were not palpable. Left foot was cool with intact capillary refill, some digit mottling and dependent rubor. No cyanosis or ulcerations. Non invasive studies: ABI : Right-139 (0.87)/ Left-60 (0.56). Toe Pressures : 89 (0.56)/ 43 (0.32). Imaging: CT angiogram Aortic bifurcation with severe calcification Small common iliac arteries with severe calcification on the left side 2
Bilateral CFA calcification worse on the left Patent profunda femoris arteries bilaterally Angiogram Outside Hospital L CFA shows severe calcification and stenosis 3
What would you do? A. Aortobifemoral bypass with femoral artery endarterectomy. B. Left iliac stent with L Common femoral endarterectomy. C. Bilateral kissing common iliac stents with L common femoral endarterectomy. D. Right iliac stent with right to left femorofemoral bypass and left CFA endarterectomy. E. As per CLEVER trial, supervised exercise, risk factor management and guidelinedirected medical optimization. A o r t o b i f e m o r a l b y p a s s w i.. 14% L e f t i l i a c s t e n t w i t h L C... R i g h t i l i a c s t e n t w i t h r i g h... B i l a t e r a l k i s s i n g c o m m o... 38% 17% 17% 14% A s p e r C L E V E R t r i a l, s u p e... Case Management Bilateral common iliac balloon expandable covered stents in a kissing technique, left external iliac artery selfexpanding covered stent with left common femoral endarterectomy. PREINTERVENTION ANGIOGRAM POST DEPLOYMENT OF BALLOON EXPANDABLE KISSING STENTS 4
POSTINTERVENTION ANGIOGRAM TO WHAT LEVEL SHOULD THE AORTIC BIFURCATION BE RAISED? A. 1-2 cm above the native aortic bifurcation. B. 2-3 cm above the native aortic bifurcation. C. aortic bifurcation should never be raised. 79% 21% 0% 1-2 c m a b o v e t h e n a t i v e... 2-3 c m a b o v e t h e n a t i v e... a o r t i c b i f u r c a t i o n s h o u l d... ISSUES AROUND RAISING THE AORTIC BIFURCATION Greiner and colleagues showed that if the proximal end of the kissing stents overlapped by more than half of the angiographic width within the aorta their 2 year primary and assisted primary patency rate was significantly less than if the stents crossed by less than 50%. Compression phenomenon can occur with kissing stent technique- one of the kissing stents compresses the other one and diminishes the lumen until unilateral occlusion follows. Diagnosed on CT scan. WOULD YOU USE COVERED OR BARE METAL STENT IN THE COMMON ILIAC ARTERY? A. Covered stent. B. Bare metal stent. 54% 46% Ability to cross from one femoral artery to another may be eliminated. C o v e r e d s t e n t. B a r e m e t a l s t e n t. 5
COBEST RCT. N= 168 iliac arteries in 125 patients with severe aortoiliac occlusive disease. RESULTS: Covered stent was associated with less binary restenosis. Covered stent was associated with higher freedom from occlusion than bare metal stent (but did not reach statistical significance). TASC C and D lesions treated with covered stents had less binary restenosis than those treated with bare metal stents. 6