Disclosures Boston Scientific, Medical Advisory Board Endologix Corp., Consultant and trainer, AFX Aorto-Iliac Disease: Bare Metal, Covered or Stent Grafts How I Decide John S. Lane III MD, FACS Professor of Vascular Surgery, UC San Diego Director, Endovascular Surgery, Sulpizio Cardiovascular Center Chief, Vascular Surgery, La Jolla VA Hospital UCSF Vascular Symposium 2016 Iliac Stenting: How could I mess this up? Surgery vs. Stenting: Gold Standard? Aortobifemoral bypass graft STILL the gold standard for iliac revascularization Overall operative mortality 1-4% (higher in elderly) 10 year patency 75-95% Lower in women and in CLI Percutaneous iliac intervention First introduced in 1960 s by Charles Dotter Has become the preferred method when technically feasible Acute procedural success >95% Excellent long term patency rates 1
TASC-2 Recommendations Which stent to choose? Balloon-expandable stents Balloon-expandable: Kissing Most stent in this category has similar performance Express LD only FDA-approved for iliac indication MELODIE trial (FDA indication) Prospective, single-arm, Europe/Canada (n=152) Fontaine IIa, IIb, III lesions, >50% stenosis, <10cm Technical success 98% CTA target lesion patency 97% (1yr), 94% (2yr) TLR rate 6.5% (6mo), 9.0% (1yr), 10.2% (2yr) Advantages: precise placement, high radial force Disadvantages: rigid, crush, foreshortening 2
Self-expanding stents Self-expanding: EIA tortuosity Cordis Smart Control, BS Epic, Cook Zilver, etc. Made of self expanding Nitinol (Nickel titanium) Wallstent: elgiloy (nickel, cobalt, chromium, iron) CRISP study: Primary patency (1yr) 94.7% Smart, 91.1% Wallstent Cook Zilver: Patency 92.9%, (12mo) Advantages: constant outward force, flexible, crush resistant Disadvantages: low-radial force, imprecise placement Covered Stent (self-expanding) Gore Viabahn : EIA occlusion Gore Viabahn, Bard Fluency Viabahn FDA approval for iliac indication eptfe with external nitinol frame, heparin-bonded FDA trial: 61 limb in 53 patients, stenoses & occlusions Primary patency (1yr) 91%, secondary 95% Advantages: flexible, prevent extravasation with vessel rupture, can treat aneurismal disease, prevent intimal hyperplasia (in stent) Disadvantages: larger sheath size, cover collateral, dramatic occlusion events, cost 3
Covered stents (balloon-expandable) Atrium icast : Iliac CTO/Aneurysm Atrium icast tracheobronchial indication COBEST trial: covered (V12) vs bare metal (Australia) Binary restenosis (18mo): 94.5% icast, 82.2% BS TASC C/D: significantly improved restenosis, occlusion, Rutherford class Advantages: CTO, high radial force, over-dilatate, aneurysmal disease, prevent intimal hyperplasia (in stent), cover rupture/bailout Disadvantages: larger sheath size (relative), cover collateral, cost Stent Grafts Endologix AFX : Heavy Aortic Calcium Paucity of literature for AIOD CERAB technique: aortic cuff, 2 covered stents Endologix AFX (smallest 22mm x 11mm) 17Fr ID sheath, 9Fr contralateral Maldonado (Veith): 80pts, 9 centers, 80% TASC-D Primary patency (1yr) 94%, assisted 96.7% Advantages: treat aortic occlusive disease, treat concomitant aortic aneurysm, prevent rupture (Ca++), aggressive oversize, preserve Ao bifurcation Disadvantages: largest sheath size, cover additional vessel length, low radial force (balloon-expandable) 4
TASC D Lesions Endologix AFX : CTO Summary: How I do it Courtesy of Zachary Arthurs, MD Bare metal Balloon expandable: Ostial lesions, high radial force needed, low-rupture risk (stenoses, short occlusion) Self expanding: non-ostial lesions, tortuosity, long external iliac stenoses Covered Balloon expandable: Ostial lesions, CIA CTO (higher rupture risk), restenoses, iliac aneurysm Self-expanding: non-ostial, EIA CTO, iliac aneurysms, crack and pave Stent Grafts Extensive aortic component, concomitant AAA Hope I guessed right 5