Aortoiliac Stenting Research Articles

A Belgian physician-initiated trial investigating the LifeStream peripheral stent graft system for the treatment of complex TASC C and D iliac lesions.

Due to the heterogeneity of literature findings, stent type selection for the endovascular treatment of complex aorto-iliac occlusive disease remains challenging. The BELSTREAM study, a physician-initiated, prospective, multicenter, single-arm study, aims to report the safety and efficacy of the balloon expandable LifeStream Peripheral Stent Graft System (BD, Tempe, Arizona, USA) for the treatment of complex TASC C and D aorto-iliac artery lesions. Seventy patients and 133 lesions were included at six Belgian institutions. The primary efficacy endpoint of the study is primary patency at 12 months' follow-up. The primary safety endpoint is freedom from periprocedural serious adverse events (SAEs). Primary patency rate at 12-month follow-up was 94.5%. Target Lesion Revascularization (TLR) was reported in three patients at 12-month follow-up, resulting in a freedom from TLR rate of 95.3%. In a subgroup of patients with aorto-iliac stenting in kissing configuration, primary patency at 12-month follow-up was 97.4% with freedom from TLR 97.9%. Freedom from a negative primary safety outcome (NPSO) was 100% at 30 days in the overall study patient population. The patency and freedom from TLR rates, low adverse event rates, and up to one year sustained improvement in clinical outcomes demonstrate that the LifeStream™ Balloon Expandable Vascular Covered Stent is a well-suited device for the treatment of complex TASC C and D lesions, the challenging kissing configuration included.

Incidence and Risk Factors of Iliac Artery Rupture during Aortoiliac Stenting.

Aortoiliac occlusive disease (AIOD) is widely prevalent and leads to severe claudication or chronic limb-threatening ischemia. Stent placement for AIOD demonstrated excellent outcomes in terms of long-term patency. However, iliac artery rupture is the most fearful complication during the aortoiliac stenting (AIS). This study aimed to evaluate the incidence and risk factors of iliac artery rupture during AIS. A retrospective review of consecutive patients with AIOD treated with AIS from 2009 to 2021 was completed. We excluded patients with instent restenosis. All types of stents, including self-expanding stent (SES), balloon-expandable stent (BES), or balloon-expandable covered stent (CS), were used. Angiographic characteristics and procedural outcomes were analyzed. Procedural success was defined as the residual stenosis <30%. A total of 242 patients (86.8% male; mean age 68.8±10.0 years) with de novo AIOD were treated with AIS. The procedural success rate was 100%. Rupture occurred in six patients (2.5%) and all ruptures were occurred in the external iliac artery (EIA). Stenting of the EIA and less calcified lesion were risk factors for iliac rupture (P=0.028). All cases of iliac artery rupture were successfully treated with the CSs. Overall primary patency rates were 98.0% and 93.4% at 12 and 36 months, respectively. Primary patency rates of SES, BES, and CS were 87.7%, 88.4%, and 100% at 36 months, respectively. The incidence of iliac artery rupture during AIS was 2.5%. Stent placement in the less calcified lesion and EIA was a risk factor for rupture during AIS. Placement of the CS can be the straightforward solution in case of iliac artery rupture during AIS.

A Fenestrated Balloon Expandable Stent System for the Treatment of Aortoiliac Occlusive Disease.

In aortoiliac occlusive disease, atherosclerotic plaques can occlude the distal aortic bifurcation and proximal bilateral iliac artery and thus cause ischemia in the lower extremity. This is typically treated by restoring patency with balloon expandable stents. Stents are typically deployed in a "kissing stent" configuration into the bilateral iliac arteries and into the distal aortic bifurcation lumen to restore antegrade arterial flow. However, these stents typically become re-occluded by plaques. To understand the reasons for this and look for solutions, we simulated flow dynamics in the aortic bifurcation in the presence and absence of stents using computational fluid dynamics. Results demonstrated that the kissing stent configuration was associated with high levels of vorticity and flow constriction. These prothrombotic variables were alleviated in an alternative, aortoiliac fenestrated (AIFEN), tapered, and balloon-expandable stent design. Our findings suggest that stent design can be tailored to improve flow fields for aortoiliac stenting.

Intravascular Ultrasound Imaging During Aortoiliac Stenting: No Impact on Outcomes at 1 Year

Purpose To investigate the effect of intravascular ultrasound (IVUS) imaging use on clinical outcomes after aortoiliac stenting in patients with peripheral artery disease (PAD). Materials and Methods Subjects for this retrospective analysis were derived from the OMOTENASHI registry database, which contained 803 symptomatic PAD patients (Rutherford categories 2–4) who were treated with self-expanding stent implantation for aortoiliac atherosclerotic lesions at 61 centers in Japan between January 2014 and April 2016. Of the 803 patients, 545 (67.9%) patients (mean age 73±9 years; 453 men) underwent IVUS-supported stent implantation and were compared with the 258 patients (mean age 73±8 years; 217 men) treated without IVUS. A propensity score analysis of 138 matched pairs was conducted to compare treatment strategies and clinical outcomes between patients having IVUS-supported endovascular therapy and those treated without IVUS. Results Endovascular strategies and postoperative medications were not significantly different between the IVUS and no-IVUS groups. A procedure time under 1 hour was less frequent in the IVUS group, which had a longer fluoroscopy time. The 12-month restenosis rate was not significantly different between the 2 groups [10.2% (95% CI 6.9 to 14.9%) vs 10.3% (95% CI 5.4 to 18.6%), p=0.99]. There was no interaction between baseline characteristics and the association of IVUS use with restenosis risk. Conclusion Propensity score matching analysis revealed that duration and fluoroscopy time during IVUS-supported procedures were significantly longer than in cases without IVUS use, whereas the 12-month restenosis rate was not significantly different between the groups. IVUS use in aortoiliac lesions may be unnecessary.

Independent predictors of loss of primary patency at 1 year after aortoiliac stent implantation.

To identify the risk factors for restenosis at 1year after aortoiliac stenting for symptomatic peripheral artery disease in real-world practice. We performed subgroup analysis of a large-scale prospective multicenter registry study enrolling Japanese patients with peripheral arterial disease who underwent aortoiliac endovascular therapy from April 2014 to April 2016. The subgroup comprised 880 patients (1108 limbs) who received iliac stenting. The Rutherford class was 2, 3, and 4 in 42%, 51%, and 7% of the patients, respectively. TASC II class D disease was noted in 18% of the patients and 35% had chronic total occlusion. Mean total stent length was 82.1 ± 48.5 mm and minimum stent diameter was 9.0 ± 1.3 mm. Balloon-expandable stents were used in 8% of the limbs. Concomitant femoropopliteal lesions were present in 36% of the limbs with aortoiliac lesions. In the overall patient population, the risk of restenosis at 1 year after stenting was 11.4%. Femoropopliteal lesions and the minimum stent diameter were identified as independent risk factors for restenosis at 1 year. When the study population was stratified according to these two risk factors, the restenosis rate at 1 year was 27.1% in the patients with a minimum stent diameter < 8 mm and femoropopliteal lesions, whereas it was only 5.3% in those with a minimum stent diameter ≥ 10mm and no femoropopliteal lesions. Femoropopliteal lesions and a smaller stent diameter were independent risk factors for restenosis at 1 year after aortoiliac stenting.

P4704The efficacy of intravascular ultrasound for patients with peripheral artery diseases presenting aorto-iliac artery disease

Abstract Background The use of intravascular ultrasound (IVUS) promotes better clinical outcomes for intervention in complex lesions. However, the data demonstrating whether use of IVUS improves primary patency following stenting for aorto-iliac lesions in patients with peripheral artery disease (PAD) are limited. Purpose The purpose of the current study was to investigate the impact of IVUS use on primary patency 12 months after stent implantation for aorto-iliac lesions. Methods We analyzed a clinical database of the OMOTENASHI registry (Observational prospective Multicenter registry study on Outcomes of peripheral arTErial disease patieNts treated by AngioplaSty tHerapy in aortoIliac artery), registering symptomatic PAD patients (Rutherford category 2, 3, or 4) undergoing endovascular therapy for aorto-iliac lesions between January 2014 and April 2016 in Japan. The current study analyzed 803 patients who underwent self-expandable stent implantation at 61 centers with the institutional volume known. The primary endpoint was 12-month restenosis, defined as ≥50% stenosis on computed tomography or angiography, or a peak systolic velocity ratio ≥2.5 on duplex ultrasound. When treatment strategies, endovascular procedures and clinical outcomes were compared between the patients treated with IVUS use and those treated without IVUS use, the propensity score matching was performed to minimize the inter-group difference in baseline characteristics. Results A total of 545 patients (67.9%) underwent IVUS-supported stent implantation. Patients treated with IVUS use had a lower prevalence of regular dialysis, whereas they had a higher prevalence of TASC II class D and chronic total occlusion. In patients treated with IVUS use, carbon dioxide contrast agent were more often used, and 0.035-inch guidewire was less frequently selected. Implanted stents in these patients were longer and smaller in diameter. The propensity score matching extracted 138 pairs, with no remarkable intergroup difference in baseline characteristics. Procedure time ≤1 hour was less frequent in patients treated with IVUS use; their radiation time was longer. Endovascular strategies, as well as postoperative medication were not significantly different between patients with and without IVUS use. The 12-month restenosis risk was not significantly different between patients with and without IVUS use (10.2% [6.9 to 14.9%] versus 10.3% [5.4 to 18.6%], P=0.99). Conclusion IVUS use in aorto-iliac stenting for patients with PAD was not associated with primary patency at 12 months. Acknowledgement/Funding None

Risk factors for perioperative mortality after revascularization for acute aortic occlusion

ObjectiveAcute aortic occlusion (AAO) is a life-threatening event necessitating prompt revascularization to the pelvis and lower extremities. Because of its uncommon nature, outcomes after revascularization for AAO are not well characterized. Our aim was to describe the perioperative morbidity and mortality associated with revascularization and to identify the patients at highest risk. MethodsA retrospective chart review was performed of patients who presented to our institution from 2006 to 2017 with acute distal aortic occlusion. Patients with a prior aortofemoral bypass were excluded, but those with aortoiliac stents were included. Baseline demographics and comorbidities, preoperative clinical presentation and imaging, procedural details, and postoperative hospital course were reviewed. The primary outcome was 30-day mortality, and major complications were evaluated as secondary outcomes. Logistic regression models were constructed to identify factors associated with 30-day mortality. ResultsWe identified 65 patients who underwent revascularization for AAO. Median age was 63 years (range, 35-89 years), and 64.6% were male; 56.4% of patients presented within 24 hours of symptom onset, and 43.8% were treated within 6 hours of presentation. There were particularly high rates of prior coronary artery disease (62.3%) and chronic obstructive pulmonary disease (41.0%); 18.5% had prior iliac stents. Preoperative imaging in 44 patients showed occlusion of the inferior mesenteric artery in 36.0% and both internal iliac arteries in 34.7%. Treatments for revascularization included axillobifemoral bypass (55.4%), aortoiliac thromboembolectomy (15.4%), aortobifemoral bypass (13.9%), and aortoiliac stenting (15.4%). Overall 30-day mortality was 27.7% and was not affected by treatment modality. Mortality was highest in patients older than 60 years (40.5% vs 10.7%; P = .01) and those presenting with lactate elevation (45.5% vs 5.9%; P = .004) or motor deficit in at least one extremity (36.6% vs 9.5%; P = .03). Univariate predictors of 30-day mortality were age ≥60 years (odds ratio [OR], 5.68; 95% confidence interval [CI], 1.45-22.26; P = .01), presentation with motor deficit (OR, 5.48; 95% CI, 1.12-26.86; P = .04), presentation with elevated lactate level (OR, 13.33; 95% CI, 1.58-11.57; P = .02), history of prior stroke (OR, 4.80; 95% CI, 1.21-18.97; P = .03), and bilateral internal iliac artery occlusion (OR, 7.11; 95% CI, 1.54-32.91; P = .01). At least one postoperative complication was observed in 78.5% of patients, including acute kidney injury (56.9%, with 21.5% requiring hemodialysis), respiratory complications (46.2%), cardiovascular complications (33.9%), major amputation (15.4%, bilateral in 7.7%), and bowel ischemia (10.8%). ConclusionsEven with prompt revascularization and despite the chosen treatment modality, AAO carries high risk of mortality and numerous life-threatening complications. Older patients presenting with elevated lactate levels, motor deficit, and bilateral internal iliac artery occlusions are at the highest risk of perioperative mortality. These factors may aid in risk stratification and managing expectations in this critically ill population.

The Effect of Revascularization on the Hemodynamic Profile of Patients with Infrarenal Aortic Occlusion

Patients undergoing revascularization for infrarenal aortic occlusion (IAO) have been reported to present improved survival rates compared to those treated conservatively. Aim of this study was to investigate the hemodynamic changes induced after revascularization for IAO, as expressed with pulse wave velocity (PWV), augmentation index (Aix), augmentation pressure (AP), and pulse wave reflection coefficient (RC). Twelve patients underwent revascularization (9 aortobifemoral/aortobiiliac bypasses, 2 primary iliac stenting, and 1 hybrid procedure of unilateral aortoiliac stenting and crossover bypass). Calculation of hemodynamic parameters was performed in all patients preoperatively, at 1 month, and 1 year postoperatively. Pulse wave analysis was performed noninvasively with a novel validated brachial cuff-based automatic oscillometric device (Mobil-O-Graph; IEM, Stolberg, Germany). The estimated hemodynamic parameters were AIx, AP, RC, and PWV. Data were analyzed with the Friedman analysis of variance test. Aix decreased significantly at 1 month and further at 1 year postoperatively compared to preoperative values (24±11 and 17±13 vs. 34±13.5, respectively, P = 0.0006). AP decreased at 1 month and 1 year postoperatively compared to preoperative values (6.5 ± 4mm Hg and 8±6.5mm Hg vs. 13±12mm Hg, respectively, P = 0.045). RC decreased also at 1-month and 1-year postoperatively compared to preoperative values (62±5.5, 64±4.3 vs. 73±5.1, respectively, P = 0.002). However, changes in PWV were less prominent in this short-term postoperative period. Improved hemodynamic profile may theoretically contribute to the enhanced survival rates of these patients.

Blood flow velocity prediction in aorto-iliac stent grafts using computational fluid dynamics and Taguchi method

Covered Endovascular Reconstruction of Aortic Bifurcation (CERAB) is a new technique to treat extensive aortoiliac occlusive disease with covered expandable stent grafts to rebuild the aortoiliac bifurcation. Post stenting Doppler ultrasound (DUS) measurement of maximum peak systolic velocity (PSVmax) in the stented segment is widely used to determine patency and for follow up surveillance due to the portability, affordability and ease of use. Anecdotally, changes in hemodynamics created by CERAB can lead to falsely high PSVmax requiring CT angiography (CTA) for further assessment. Therefore, the importance of DUS would be enhanced with a proposed PSVmax prediction tool to ascertain whether PSVmax falls within the acceptable range of prediction. We have developed a prediction tool based on idealized models of aortoiliac bifurcations with various infra-renal PSV (PSVin), iliac to aortic area ratios (R) and aortoiliac bifurcation angles (α). Taguchi method with orthogonal arrays (OA) was utilized to minimize the number of Computational Fluid Dynamics (CFD) simulations performed under physiologically realistic conditions. Analysis of Variance (ANOVA) and Multiple Linear Regression (MLR) analyses were performed to assess Goodness of fit and to predict PSVmax. PSVin and R were found to contribute 94.06% and 3.36% respectively to PSVmax. The Goodness of fit based on adjusted R2 improved from 99.1% to 99.9% based on linear and exponential functions. The PSVmax predictor based on the exponential model was evaluated with sixteen patient specific cases with a mean prediction error of 9.9% and standard deviation of 6.4%. Eleven out of sixteen cases (69%) in our current retrospective studies would have avoided CTA if the proposed predictor was used to screen out DUS measured PSVmax with prediction error greater than 15%. The predictor therefore has the potential to be used as a clinical tool to detect PSVmax more accurately post aortoiliac stenting and might reduce diagnostic errors and avoid unnecessary expense and risk from CTA follow-up imaging.

Long-Term Outcomes of Endovascular Therapy for Aortoiliac Bifurcation Lesions in the Real-AI Registry

To report long-term outcomes of endovascular therapy (EVT) for aortoiliac bifurcation lesions. Patients enrolled in the multicenter REtrospective AnaLysis of Aorto-Iliac stenting (REAL-AI) registry in Japan were pooled. Of 2096 patients who underwent EVT for de novo aortoiliac disease between January 2005 and December 2009, 190 patients (148 men; mean age 70±9 years) had aortoiliac bifurcation lesions that were treated with stents, whose configuration (single, V, or kissing) and type (balloon-expandable or self-expanding) were subjected to regression analysis to determine any impact on primary patency along with other demographic, clinical, and lesion characteristics, including Trans-Atlantic Inter-Society Consensus II C/D classification. The primary endpoints were restenosis and target lesion revascularization (TLR). Secondary endpoints were all-cause death, major cardiovascular events, and major cardiovascular + limb events. The overall complication rate was 6.3%, and 1- and 5-year primary patency rates were 87% and 73%, respectively. Over a mean follow-up of 31±15 months, there were 36 (19.0%) restenoses, 22 (11.6%) TLRs, and 4 (2.1%) reocclusions; stent fracture (2, 1.1%) and major amputation (2, 1.1%) were rare. Only female gender [adjusted hazard ratio (AHR) 4.26, 95% CI 1.89 to 9.71, p<0.001] and residual diameter stenosis (AHR 1.04, 96% CI 1.01 to 1.06, p=0.01) were independent predictors of primary patency. Stenting for aortoiliac bifurcation lesions was found to be safe and effective. Neither stent configuration nor type appeared to affect vessel patency in true bifurcation lesions.

Perioperative Complications After Aorto-iliac Stenting: Associated Factors and Impact on Follow-up Cardiovascular Prognosis

To investigate factors associated with 30-day perioperative complications (POC) after aorto-iliac (AI) stenting, and to compare follow-up cardiovascular prognosis between patients with and without POC. This was a retrospective multicenter study. We used a multicenter database of 2012 consecutive patients who successfully underwent AI stenting for peripheral arterial disease in 18 centers in Japan from January 2005 to December 2009 to analyze independent predictors of POC and impact of POC on prognosis by logistic regression and a Cox proportional hazard regression model, respectively. Mean age was 71 ± 9 years (median: 72 years; range: 37-98 years), and 1,636 patients (81%) were men. POC occurred in 126 patients (6.3%). In multivariate logistic regression analysis, old age (≥80 years), critical limb ischemia (CLI), and Trans Atlantic Inter-Societal Consensus (TASC) II class C/D were independently associated with POC with adjusted odds ratios and 95% confidence intervals (CI) of 1.9 (1.3-2.9), 2.3 (1.5-3.4), and 2.4 (1.6-3.4), respectively. Out of 2012 patients, 1995 were followed up for more than 30 days (mean: 2.6 ± 1.5 years; range: 2-2,393 days). In a Cox hazard regression model adjusted for baseline clinical characteristics, POC was positively and independently associated with follow-up major adverse cardiac events (adjusted hazard ratio [HR]: 1.9; 95% CI: 1.3-2.8; p = .002), but not with major adverse limb events and target lesion revascularization (adjusted HR: 1.4; 95% CI: 0.7-2.7; p = .25; and adjusted HR: 1.2; 95% CI 0.6-2.6; p = .568), respectively. Age >80 years, CLI, and TASC C/D lesion were positively associated with POC after AI stenting. Occurrence of POC appears to adversely affect follow-up cardiovascular, but not limb and vessel prognosis.

Perioperative complications following aorto-iliac stenting in patients with peripheral artery disease

Perioperative complications following aorto-iliac stenting in patients with peripheral artery disease

Exercise, Stenting Beat Medical Therapy in Peripheral Disease

Orlando – In elderly patients with aortoiliac peripheral artery disease, adding supervised exercise to optimal medical therapy offers better treadmill walking performance than does aortoiliac stenting. On the other hand, aortoiliac stenting plus optimal medical care results in better quality of life than does supervised exercise, according to the 6-month results of the CLEVER (Claudication vs. Endoluminal Revascularization) trial. “This idea that you can go home and walk isn't, and hasn't been, effective,” coauthor Dr. Alan Hirsch said at the annual scientific sessions of the American Heart Association. CLEVER is the first prospective, head-to-head, comparative trial of three guideline-recommended interventions: supervised exercise, stenting, and optimal medical therapy. CLEVER randomized 111 patients to either optimal medical care, (OMC) including cilostazol (Pletal) 100 mg twice daily, plus advice about home exercise and diet with monthly coordinator contact; OMC plus supervised exercise for 1 hour thrice weekly for 26 weeks; or OMC plus aortoiliac stenting. All patients had moderate to severe claudication. The patients averaged 64 years of age. Their baseline ankle-brachial index was 0.68, peak walking time was about 5 minutes, and claudication-onset time was 1.5 minutes. The primary endpoint of change in peak walking time from baseline to 6 months was just 1.2 minutes in the OMC group, compared with 5.8 minutes in the supervised exercise group and a clinically significant 3.7 minutes in the stenting group, said Dr. Hirsch, director of the vascular medicine program at the University of Minnesota in Minneapolis. The changes were significantly different between supervised exercise and OMC (4.6 minutes), stenting and OMC (2.5 minutes), and supervised exercise and stenting (2.1 minutes). Self-reported quality-of-life scores on the Walking Impairment Questionnaire and Peripheral Artery Questionnaire improved significantly with supervised exercise plus stenting, compared with OMC for most domains including walking distance, walking speed, stair climbing, physical limitation, social limitation, and summary score. The improvements were significantly greater with stenting than with supervised exercise for three of the four domains that were evaluated on each questionnaire. Dr. Hirsch said the quality-of-life finding raises questions that CLEVER was not designed to answer, and he hoped the trial would inspire future research. Invited discussant Dr. Michael Conte, codirector of the Heart and Vascular Center at the University of California San Francisco, said, “We actually have a lot of evidence that supervised exercise works, but we don't have reimbursement. “So until we get reimbursement, we will not be able to offer this to our patients, and the Medicare beneficiaries are the largest group with PAD.” Dr. Conte added that reimbursement for stenting is significant and not linked to outcomes, and providers and industry are therefore incentivized to provide invasive treatments. The study, led by Dr. Timothy Murphy, medical director of the vascular research center at Brown University in Providence, R.I., was simultaneously published online in Circulation. Dr. Hirsch reported support for this trial and other research from Cordis/Johnson & Johnson, eV3, Boston Scientific, Otsuka America, Abbott Vascular, Cytokinetics, and Viromed, AstraZeneca, Merck, Novartis, and Pozen. Dr. Conte reported that he had no conflict of interest.

Contemporary Outcomes After Endovascular Treatment for Aorto-Iliac Artery Disease

The patency and complications in aorto-iliac (AI) stenting remain poorly understood. The aim of this paper was to investigate the safety and efficacy after AI stenting. This study was performed as a large-scale multicenter, retrospective registry. A total of 2,147 consecutive patients with AI disease were enrolled. The safety endpoints were procedure success, complications and 30-day mortality. The efficacy endpoints were primary, assisted primary and secondary patency, overall survival, freedom from major adverse cardiovascular events (MACE; all-cause death, myocardial infarction and stroke), and major adverse cardiovascular and limb events (MACLE; any repeat revascularization for limb and leg amputation in addition to MACE). Procedure success, complication rate and 30-day mortality were 97.6%, 6.4% and 0.7%. Primary patency was 92.5%, 82.6% and 77.5% at 1, 3 and 5 years, assisted primary patency was 97.0%, 92.7% and 91.9% at 1, 3 and 5 years and secondary patency was 99.0%, 98.7% and 98.5% at 1, 3 and 5 years. The overall survival rate was 95.0%, 87.6%, and 79.3% at 1, 3 and 5 years. The cause of death was cardiovascular in 44.1%. Freedom from MACE (MACLE) was 93.3% (89.9%), 84.4% (76.7%), and 74.9% (66.8%) at 1, 3 and 5 years. Female gender, diabetes, renal failure, absence of aspirin, reference vessel diameter <8.0mm and outflow lesion were found to be independent predictors of primary patency. The safety and efficacy after AI stenting are feasible compared to surgical reconstruction.

A Contemporary Comparison of Aortofemoral Bypass and Aortoiliac Stenting in the Treatment of Aortoiliac Occlusive Disease

Although aortofemoral bypass (AFB) has historically been the treatment of choice for aortoiliac occlusive disease (AIOD), rates of AFB have declined, while utilization of aortoiliac angioplasty and stenting (AS) has increased dramatically. The objective of the current study was to determine the effect of these trends on treatment outcomes in a contemporary single-institution experience with AIOD. Between 1997 and 2007, 118 AFB and 174 AS procedures were performed in 161 men (55.1%) and 131 women at a single university teaching hospital. Patient outcomes were retrospectively reviewed and analyses were performed using chi-squared/Fisher's exact test and ANOVA. Ankle-brachial index (ABI) interactions between procedure type and Trans-Atlantic Inter-Society Consensus (TASC) category were calculated using a General Linear Model. A reduced Cox model was used to determine the impact of patency, presenting symptoms, duplex surveillance, and procedure type on amputations and revisions. Kaplan-Meier estimates for survival, freedom from amputation, and freedom from revision were used to evaluate long-term outcomes. There was no difference between AFB and AS groups with respect to 30-day mortality (0.8% and 1.1%, p=0.64), myocardial infarction (1.7% and 1.1%, p=0.53), cerebrovascular accident (0.0% and 1.1%, p=0.35), or renal failure requiring hemodialysis (3.4% and 1.2%, p=0.19). AFB was associated with increased surgical complication rates including the need for emergency surgery (6.8% and 1.7%, p=0.029), infection/sepsis (16.1% and 2.3%, p<0.001), transfusion (16.1% and 5.7%, p=0.004), and lymph leak (8.5% and 0.6%, p=0.001). The difference between preprocedural and postprocedural ABI was greater for AFB than AS (R, 0.39 and 0.18, p<0.001; L, 0.41 and 0.15, p<0.001). This difference was maintained when patients were stratified by TASC category. There were no differences between the AFB and AS groups with respect to long-term rates of mortality, amputation, or revision procedures. AFB continues to be performed safely, despite the case numbers in this series correlating with a lower-volume hospital. Morbidities associated with major open surgery in this series were counterbalanced by greater improvements in ABI. Patients and practitioners should continue to entertain both procedure types as viable alternatives for the treatment of AIOD.

Results of endovascular therapy and aortobifemoral grafting for Transatlantic Inter-Society type C and D aortoiliac occlusive disease

The purpose of this study was to compare the outcomes of aortoiliac stenting (AIS) to those of aortobifemoral grafting (ABF) for patients with TransAtlantic Inter-Society Consensus (TASCII) C and D aortoiliac occlusive disease. From 1998 to 2007, 32 patients underwent ABF and 40 patients underwent AIS. Kaplan-Meier estimates for patency were used. Patients undergoing AIS were older (66.6 years ABF vs 59.2 years AIS; P=.006). The ABF group had simultaneous profundoplasty (n = 8) and femoral-popliteal graft (n =1). Six patients had treatment for concomitant infrainguinal disease at the time of AIS. There was no mortality in either group. Average hospital stay in the ABF group was 7 +/- 2 days and 1 +/- 0.3 days for AIS (P = .0001). Pulmonary complications predominated in the ABF group (13%). Four patients in the AIS group (10%) developed intraprocedural complications. Primary patency at 48 months was 69 +/- .12% for AIS and 93 +/- .07% for ABF (P = .013). There was a significant increase in ankle-brachial indices after revascularization in both groups. TASC type C and D lesions can be treated with either ABF or AIS with satisfactory results. Compared with ABF, AIS is associated with decreased primary patency, decreased perioperative morbidity, and shorter hospital stay.

Acute limb ischemia associated with type B aortic dissection: Clinical relevance and therapy

The goal of the current study is to characterize the presentation, therapy, and outcomes of acute limb ischemia (ALI) associated with type B aortic dissection (AoD). The prospective/retrospective International Registry for Acute Aortic Dissection (IRAD) database and a single institutional database were queried for all patients with type B AoD from 1996 to 2002. Univariate and multivariate statistics were used to delineate factors associated with morbidity and mortality outcomes. According to the IRAD data (n = 458), the mean age of patients was 64 years, and 70% were men. The overall mortality was 12%; of these, 6% had ALI. Pulse (3-fold) and neurologic deficits (5-fold) were more common in those with ALI (P < .001). Endovascular, but not surgical therapy, was more commonly performed in patients with ALI compared with those without ALI (31% vs 10%, P = .004). No difference in age, race, gender, or origin of dissection was observed. ALI was associated with acute renal failure (odds ratio [OR] = 2.7; 95% confidence interval [CI] 1.1-7.1; P = .048) and acute mesenteric ischemia/infarction (OR = 6.9; 95% CI 2.5-20; P < .001). Adjusting for patient characteristics, ALI was associated with death (3.5; 95% CI 1.1-10; P = .02). The single institution analysis revealed similar patient demographics and mortality in 93 AoD patients, of whom 28 had ALI. Aortic fenestration or aorto-iliac stenting was the primary therapy in 93%; surgical bypass was used in 7%. Limb salvage was 93% in those with ALI at a mean of 18 months follow-up. The number of organ systems with malperfusion was 2-fold higher at aortography than suspected preprocedure (P = .002). By stepwise regression modeling, mortality was greater in those not taking a beta-blocker (OR = 19; 95% CI 3.1-111; P = .001). ALI secondary to AoD is predictive of death and visceral ischemia. Endovascular therapy confers excellent limb salvage and allows diagnosis of unsuspected visceral ischemia.

A new technique for hypogastric artery embolization

We report a new procedure for embolization of hypogastric arteries simultaneously with aortoiliac stenting. Eight patients with aortoiliac (n = 6) and iliac (n = 2) aneurysms have been treated with this procedure. The technique involves the placement of a hook catheter near the hypogastric artery or in the sac, and the endoprosthesis insertion is done by using the same arteriotomy. The endoprosthesis is deployed and the coil is released. Saline is injected into the sac. The catheter is removed and the balloon at the distal end of the endoprosthesis is inflated. Computed tomography images showed periprosthesis or aneurysm thrombosis. No endoleaks or coils displacement in the sac were found.

Duplex Follow-up of Aorto-iliac Stents

Objectives to assess the feasibility of duplex follow up of aorto-iliac stents. Material and methods in addition to standard clinical and ankle/brachial pressure assessment, 75 patients undergoing aorto-iliac stenting for atherosclerotic disease were prospectively followed up with duplex ultrasound at 3 monthly interval up to 1 year and then annually. We attempted to directly visualise the stents wherever possible using standard 2D imaging, standard and power Doppler, as well as spectral Doppler. Patients had an angiogram at 12 months or sooner if a problem was identified on the duplex scan. Results mean follow up was 14 months (2–36). Complete visualisation of the pelvic arterial tree was achieved in 94% of scans. All patients had at least one satisfactory scan. Duplex detected 30 lesions in 23 patients. Twenty-seven lesions were confirmed at angiography. There were two false positives. Overall sensitivity, specificity and accuracy were 100%, 93% and 96% for patient undergoing angiography. Conclusion duplex ultrasound follow up is feasible in the majority of patients.

Stenting for localised arterial stenoses in the aorto-iliac segment.

to determine complications and patency following angioplasty (PTA) and stenting of aorto-iliac stenoses. District General Hospital in U.K. prospective observational study. between December 1994 and June 2000, 50 patients (38 men), median age 64 (41-89) years underwent aorto-iliac stenting. A total of 61 stents were placed. Indications were intermittent claudication in 38 and rest pain, ulceration or gangrene in 12. Sites stented were aorta 11, common iliac artery 32, external iliac artery 14, common and external iliac arteries two. Bilateral iliac procedures were carried out in nine. Two stents were used to correct residual stenoses after aortic stenting. Some 11 recurrent stenoses were treated. The other reasons for stenting were residual stenoses greater than 30% after PTA, tight calcified stenoses or when a stenosed iliac artery was being used as a donor prior to crossover or femoropopliteal bypass. two immediate technical failures occurred due to malposition. Residual stenoses were corrected by PTA. Two further patients sustained minor complications. None of the aortic stents occluded through two required secondary procedures. Primary-assisted patency was thus 100% at three years. Primary patency following iliac stenting for claudication and critical ischaemia were 97% and 86% at three years respectively. PTA and stenting of aorto-iliac stenoses can be safely achieved with durable results.