Native Microchannel Recanalization with Orbital Atherectomy as a Viable Alternative to Failed Standard Recanalization of TASC II D Aortoiliac Occlusive Disease

Abstract

Endovascular treatment of Trans-Atlantic Inter-Society Consensus (TASC) II D aortoiliac lesions is now an accepted form of revascularization. We sought to demonstrate that native microchannel recanalization and orbital atherectomy is a successful recanalization method of TASC II D aortoiliac lesions refractory to standard recanalization techniques. Four consecutive patients from 2016 to 2018 with symptomatic TASC II D aortoiliac occlusive disease prohibitive for open bypass and failed traditional prodding guidewire or device recanalization technique were identified and underwent advanced native microchannel selection and subsequent orbital atherectomy (Cardiovascular Systems, Inc, St Paul, MN). Native microchannels of the calcified lesions were probed and traversed with a 0.014″ wire. The atherectomy crown was tracked over the wire, and orbital atherectomy was initiated with a 1.25mm crown starting at the lowest revolution and continued until the microchannel is sufficiently large to track a 1.2mm-balloon for angioplasty. Serial microchannel angioplasty with exchange for stiffer and/or larger profile wires and balloons was achieved until a covered stent could be safely deployed across the target lesion. The kissing stent technique was then used to recreate the aortic bifurcation. A ViperSlide lubricant solution was used in all cases per indication for use. Patients were all heparinized to maintain an activated clotting time of 250. Lesion characteristics, survival, limb salvage, patency, and change in clinical symptoms were also analyzed. All 4 patients underwent successful native microchannel recanalization and orbital atherectomy of the common iliac artery (CIA). There were no intraoperative ruptures, embolizations, or dissections. All 4 patients presented with unilateral CIA occlusion with contralateral CIA stenosis. The average occlusion lesion length of the CIA was 6.0cm. The average contralateral stenosis length was 2.3cm. The kissing stent technique was used in all patients for reconstruction of the aortic bifurcation. At 30days, all patients had improvement in pain and primary patency of 100%. Long-term follow-up at 21.6months noted continued improvement in symptoms and primary patency of 75%. The fourth patient died at 4months from lung cancer with occluded iliac stents by imaging at that time. Native microchannel recanalization with subsequent orbital atherectomy is an option in high-risk patients with TASC II D aortoiliac disease who have failed traditional recanalization techniques. Further work in proper patient selection and safe utilization of atherectomy devices in the CIA is needed.