Primary stenting in complete aortic occlusion.

Abstract

T he introduction of intravascular stents has expanded the role of percutaneous endovascular techniques in the treatment of aortoiliac occlusive disease. The use of stents with or without preliminary thrombolysis has made percutaneous recanalization a viable alternative to surgical bypass in the treatment of complete occlusions of the iliac arteries and aorta. Only a small number of cases of successful endovascular repair of complete acetic occlusions have been reported, and all but one have involved the use of preliminary thrombolysis and percutaneous transluminal angioplasty (PTA) before stent deployment [I5]. We report a case of long-segment complete aortic and bilateral iliac artery occlusion that was successfully treated by means of primary stenting without the use of preliminary thrombolysis or PTA. Primary stenting of complete aortic occlusions is a viable alternative to surgical revascularization and can be safely accomplished without the added costs and risks of preliminary thrombolysis and PTA. A 54-year-old woman with a history of chronic progressive bilateral buttock and lower extremity claudication was referred for arteriographic evaluation. On physical examination, the femoral, popliteal, and pedal pulses were noted to be absent. Ankle brachial indexes were 0.2 bilaterally. The right common femoral artery was punctured using sonographic guidance and a Micropuncture Set (Cook, Bloomington, IN). A guidewire was advanced through the entry needle, and resistance was encountered in the mid pelvis. A 5-French sheath was introduced, and a hand injection showed complete occlusion of the common iliac artery (Fig. lA). A 0.035-inch Roadrunner guidewire (Cook) was then successfully advanced through the occluded segment and into the terminal aorta. A 5-French pigtail catheter was positioned in the terminal aorta. and aortography showed complete occlusion of the abdominal aorta just distal to the ongin of the inferior mesenteric artery (Fig. 1B). The occlusion extended into both common iliac arteries with reconstitution of the distal common iliac arteries just proximal to the origin of the internal iliac arteries. Passage of the pigtail catheter through the occluded segment appeared anatomic. The left common femoral artery was then punctured, and the occluded aortoiliac segment was traversed with a 0.035-inch Roadrunner guidewire as had been performed on the contralateral side. An injection through the pigtail catheter showed what was believed to be anatomic passage of the left guidewire through the occluded segment. The 5-French sheaths were exchanged for 30-cm-long 7-French sheaths, and these were successfully advanced into the abdominal aorta proximal to the occlusion. After IV administration of 5000 units of heparmn, P394 stents (Palmaz; Johnson & Johnson Interventional Systems, Warren, NJ) mounted on 6mm balloons were deployed bilaterally and simultaneously into the distal abdominal aorta using a “kissing stent” technique. The cephalad margins of the stents were carefully positioned just inferior to the origin of the inferior mesenteric artery. Palmaz stents were used proximally because we believed that this stent type would allow for precise positioning when deployed simultaneously in the terminal aorta and the aortic bifurcation region. After deployment of the Palmaz stents, stenting was extended into the iliac arteries using 8 x 40 mm Wallstents (Schneider, Minneapolis, MN) with slight overlap of the Palmaz stents and the Wallstents. The Wallstents were used in the iliac arteries given the extent of the segments that required stenting. The Wallstents were then dilated to a diameter of 6 mm. A small residual uncovered segment in the distal left common iliac artery was treated by use of an