Utility of Intra-operative Cone Beam Computed Tomography in Endovascular Treatment of Aorto-iliac Occlusive Disease

Abstract

Endovascular treatment of aorto-iliac occlusive disease (AIOD) is well established, but to maintain long-term patency, secondary interventions are common. Multiple stents and iliac artery tortuosity often make it difficult to evaluate stent compression intra-operatively and this might be a cause for later failure. Completion angiography (CA) and pressure gradient (PG) measurement are often used to assess the final intra-operative result. The purpose of this study was to evaluate the role of intra-operative cone beam computed tomography (CBCT) to optimize the primary operation results. Fifty-three patients (28 females) were enrolled in a prospective study. All patients underwent endovascular aorto-iliac revascularization. Final intra-operative results were evaluated with additional CBCT, after CA and PG were found to be satisfactory. Imaging findings and imaging based adjunctive procedures were recorded. One hundred and sixty five stents were placed because of AIOD. Twenty patients underwent adjunctive procedures after the primary stenting. In 24.5% (13/53) cases, adjunctive procedures were indicated solely by the CBCT findings, as both standard CA and PG were normal. Twenty-six of the 53 patients had kissing stents placed at the aortic bifurcation. Of the kissing stent patients, 34.6% required adjunctive procedures and in two thirds these stent compressions were detected only by CBCT. The use of CBCT revealed a significant number of stent compressions that were not found with CA and PG. When performing endovascular procedures at the aortic bifurcation, CBCT is an excellent intra-operative evaluation method to assess the configuration of deployed stents. In this study, CBCT improved the technical results intra-operatively, which might influence the long-term patency positively.