Aortoiliac Lesions Research Articles

TCT-788 Safety and Efficacy of Endovascular Therapy for Octogenarians with Peripheral Artery Disease presenting Intermittent Claudication due to Aortoiliac Lesions

TCT-788 Safety and Efficacy of Endovascular Therapy for Octogenarians with Peripheral Artery Disease presenting Intermittent Claudication due to Aortoiliac Lesions

Computed Tomography Fractional Flow Reserve Can Identify Culprit Lesions in Aortoiliac Occlusive Disease Using Minimally Invasive Techniques

Currently, the gold standard diagnostic examination for significant aortoiliac lesions is angiography. Fractional flow reserve (FFR) has a growing body of literature in coronary artery disease as a minimally invasive diagnostic procedure. Improvements in numerical hemodynamics have allowed for an accurate and minimally invasive approach to estimating FFR, utilizing cross-sectional imaging. We aim to demonstrate a similar approach to aortoiliac occlusive disease (AIOD). A retrospective review evaluated 7 patients with claudication and cross-sectional imaging showing AIOD. FFR was subsequently measured during conventional angiogram with pull-back pressures in a retrograde fashion. To estimate computed tomography (CT) FFR, CT angiography (CTA) image data were analyzed using the SimVascular software suite to create a computational fluid dynamics model of the aortoiliac system. Inlet flow conditions were derived based on cardiac output, while 3-element Windkessel outlet boundary conditions were optimized to match the expected systolic and diastolic pressures, with outlet resistance distributed based on Murray's law. The data were evaluated with a Student's t-test and receiver operating characteristic curve. All patients had evidence of AIOD on CT and FFR was successfully measured during angiography. The modeled data were found to have high sensitivity and specificity between the measured and CT FFR (P=0.986, area under the curve=1). The average difference between the measured and calculated FFRs was 0.136, with a range from 0.03 to 0.30. CT FFR successfully identified aortoiliac lesions with significant pressure drops that were identified with angiographically measured FFR. CT FFR has the potential to provide a minimally invasive approach to identify flow-limiting stenosis for AIOD.

TCTAP A-118 A Comparison of Combined Balloon Expandable and Self-Expandable Nitinol Stent vs Double Self-Expandable Nitinol Stents for Long Aorto-Iliac Disease

The aim of this study was to compare the outcomes of balloon-expandable/self-expandable initial stent and double self-expandable nitinol stents) for long aorto-iliac (AI) disease. From November 2005 to March 2015, 1160 patients (915 male, 1555 limbs) underwent endovascular therapy for AI lesion.

CRT-300.18 Outcomes of Stenting With Covered Stents in Aorto-iliac Lesions to Limit Restenosis

Advances in endovascular techniques and devices have improved the outcomes of percutaneous revascularization in what was once considered a primarily surgical disease. The utilization of drug-covered stents (ICAST) appears to yield improved patency rate than the 85% patency rate demonstrated with

Commentary on ‘Contrast Induced Nephropathy and Long-term Renal Decline After Percutaneous Transluminal Angioplasty for Symptomatic Peripheral Arterial Disease’

Contrastinducednephropathy(CIN)asaresultoftheadministration of radiocontrast generally leads to reversible acute kidney injury. In patients with no risk, CIN is minor and insignificant (less than 1%). 1 In patients at risk(diabetes mellitus, chronic kidneydisease) the risk isup to 15%. 2 Other factorsthatcontributeto CINarepercutaneous coronary interventions with athero-embolization during catheter manipulation, hypovolemia, or advanced heart failure with reduced renal perfusion, but also contrast related factors (type, dose). In this issue of the European Journal of Vascular and Endovascular Surgery, Sigterman and colleagues 3 report 13% of CIN after endovascularprocedureforsymptomaticperipheralarterialdisease(PAD). They identified as risk factors, pre-operative anemia, critical limb ischemia, and low pre-intervention estimated glomerular filtration rate (eGFR). 3 These findings should be taken with caution. The prospective study included only patients with single radiocontrast use. Even a “homogenous” group does not represent the real world.The BASIL trial showed that 1.9e2.4 total number of endovascular interventions are necessary inpatientswith critical limb ischemia. 4 The authorsexcludedfromthecurrentstudypatientswithendstagerenal disease.What attracts attention to this paper isthe awareness of the existence of CIN in patients having endovascular treatment of PAD. The clinical implication of CIN awareness must result in the implementation of preventive measures (before, during, and after the intervention). It is obligatory to consider potentially nephrotoxic drugs and stop them: metformin, dipyridamole, NSAIDs, but also several ACE inhibitors and angiotensin II receptor blockers (Sartans). The use of potentially nephro-protective drugs such as antioxidants (N-acetylcysteine, ascorbic acid), or statins should be taken into account. 4 Considering the type of radiocontrast agent, clinicians must find a balance between the dose and the toxicity (isomolar and low osmolar contrast agents are less nephrotoxic) and the image quality. Insufficient image quality may require a second investigation, and results in radiocontrast accumulation. Adequate oral or intravenous hydration is essential. However, in the study hydration was used selectively only in patients with low eGFR.The benefit of decline in creatinine level and eGFR was to be expected also in patients with normal eGFR. Every vascular center should specify, according to international guidelines, their standard protocol to prevent CIN. One step forward might be a personalized endovascular intervention booklet, where the creatinine level and preventive measures can be documented in order to identify those patients with continuous decline of renal function. The use of alternative methods could eliminate or reduce radiocontrast during endovascular interventions. The value of intravascular ultrasound (IVUS) as a guide to treatment, and optimizing the length of the stent and its sizing is of no concern. In arteries with calcified, thrombotic lesions, the risk of distal embolization during the procedure is real, so that visualization of the foot and lower leg arteries is important. CO2 angiography is often “assisted” by initial or final single contrast use, and the image quality is worse than in conventional angiography. The overlay, 2D perfusion angiography, or wide range of 3D imaging tools, which are in use for complex aortic aneurysms, might be an option: translation to real life and PAD is on the waiting list. Patient specific rehearsal and pre-operative simulation might reduce radiocontrast use in complex aorto-iliac lesions, especially when a contralateral approach is used for the treatment iliac and femoral lesions; but there is a long way to go. 5 In the meantime, practitioners should not frighten patients by saying they will “lose their kidney” if they undergo any diagnostic/therapeutic radiocontrast intervention.They just have to use preventive measures to hamper renal function decline and to consider the possibility of applying alternative diagnostic/therapeutic methods.

Outcomes of endovascular treatment for TASC C and D aorto-iliac lesions

The aim of this study was to evaluate the technical success rates, primary patency, and complications for TASC C and D aorto-iliac lesions treated by endovascular procedures. Additionally, the influence of the access site and the clinical outcomes were analyzed. Between 2008 and 2014, data from 39 patients with 45 chronic iliac artery stenosis and/or occlusion who were treated with endovascular treatment were retrospectively reviewed. The procedure time was longer for TASC D lesions than for TASC C lesions (163±82min vs. 105±34min; p=0.002), where there was the more common use of brachial and femoral approach simultaneously. There were two perioperative deaths associated with TASC D lesions caused by one iliac artery rupture and one postoperative hospital-acquired pneumonia. The total perioperative complication rate was higher in the TASC D lesions than in TASC C lesions [five (18.5%) vs. zero; p=0.073]. The corresponding 2-year primary patency rates were 94.9% in TASC C lesions and 88.4% in TASC D lesions. The simultaneous brachial and femoral approach took the longest procedure time (226±157min). This study demonstrated that the outcomes of endovascular treatment for TASC C and D aorto-iliac lesions were acceptable, with better technical success in TASC C lesions than in TASC D lesions. Furthermore, the 2-year patency rate for both TASC C and TASC D lesions was acceptable. Additionally, brachial access was useful for complex anatomy, but the failure rate was high.

Accuracy of Common Femoral Artery Doppler Waveform Analysis in Predicting Haemodynamically Significant Aortoiliac Lesions.

Doppler ultrasound is cost-effective and accurate noninvasive method for evaluation of peripheral arterial disease. However, there is difficulty in detection of aortoiliac lesions due to inadequate visualization of aortoiliac arteries in many patients. The Doppler waveform changes occurring distal to significant stenosis or occlusion are well documented. Accordingly, common femoral artery (CFA) Doppler waveform analysis may be used to predict haemodynamically significant proximal aortoiliac lesions. To evaluate the accuracy of Doppler waveform analysis at the CFA for diagnosing haemodynamically significant aortoiliac stenosis or occlusion in patients of peripheral arterial disease. A total of 67 patients (114 aortoiliac segments) with suspected peripheral arterial disease were retrospectively evaluated and labeled as normal or abnormal by analysing the Doppler waveform of CFA. The triphasic waveform with normal reversal pattern was categorized as normal, while low velocity biphasic or monophasic waveform were labeled as abnormal and indirect diagnosis of normal or diseased (>50% stenosis or occlusion) aortoiliac segment was made. The results were compared to intra-arterial angiography, considered as the gold standard. The Doppler waveform analysis of CFA was abnormal in 41 out of 114 common femoral arteries, while intra-arterial angiography showed significant stenosis (21 arteries) or occlusion (26 arteries) in 47 (41%) of 114 aortoiliac segments in 67 patients. Out of 67 normal aortoiliac segments seen on angiography, the CFA waveform analysis was interpreted as normal in 62 segments. An abnormal CFA waveform could diagnose significant aortoiliac lesion with 87% sensitivity, 92% specificity, 89% Positive Predictive Value (PPV), 91% Negative Predictive Value (NPV) and 90% accuracy using angiography as the gold standard. The low velocity monophasic waveform which was seen in 38 (33%) of 114 segments was reliable predictor of significant aortoiliac disease with 93% positive predictive value. CFA Doppler waveform pattern analysis is a sensitive and accurate technique for the prediction of haemodynamically significant aortoiliac stenosis or occlusion.

Abstract 19720: Jay D. Coffman Early Career Investigator Award: Comparative Efficacy of Initial Endovascular Revascularization vs. Supervised Exercise Training in Patients With Intermittent Claudication: A Meta-analysis of Randomized Controlled Trials

Introduction: Current guidelines recommend supervised exercise training (SET) as the initial treatment modality for patients with intermittent claudication (IC), in addition to optimal medical therapy. The role of endovascular revascularization (ER) as a primary treatment option has been controversial. We performed a meta-analysis to compare the efficacy of initial ER vs. initial SET in patients with IC using data from randomized controlled trials. Methods: The primary outcome was treadmill-measured maximum walking distance (MWD) at the end of follow-up. Secondary outcomes included resting ankle brachial index (ABI) and treadmill-measured ischemic claudication distance (ICD) on follow-up. Risk of adverse limb events (revascularization, amputations) was also compared between the two groups. Random effects models were used for all analyses. Results: We included 1,145 patients from nine trials with a mean follow up duration of 13.7 months (42% aortoiliac lesions; 35% stent use; mean baseline ABI 0.64 vs. 0.67 for ER vs. SET). Follow-up MWD was not significantly different between patients undergoing ER vs. SET [Weighted mean difference (WMD) (95% CI): 19.1 m (-79.6 to 117.8 m); publication bias p=0.86]. Metaregression did not identify significant differences based on stent use or presence of aortoiliac disease. ICD was also similar between the two groups [WMD (95% CI): 36.1 m (-99.4 to 171.5 m)]. In contrast, patients undergoing ER had higher resting ABI on follow-up [WMD (95% CI): 0.14 (0.11 to 0.17), p<0.0001]. Adverse limb event rates were similar [5.4% vs. 8.2%, p=0.21]. Conclusion: Compared with initial SET, initial ER significantly improves resting ABI values. Although longer walking distance and lower rates of adverse limb events also appeared favorable for ER, these differences were not statistically significant in these intermediate term studies. Longer-term studies and those incorporating contemporary revascularization techniques are necessary.

Surgical treatment of patients with critical ischemia of lower limbs originating from aortoiliac lesions and concomitant coronary artery disease

The study focuses on the outcomes of surgical treatment of 236 patients with critical ischemia of lower limbs originating from aortoiliac lesions and concomitant coronary artery disease. All patients first underwent vascular surgery, with 158 of them having aortobifemoral bypass surgery and 78 - hybrid vascular procedures on the aortoiliac segment: open surgical revascularization of femoral arteries and angioplasty and stenting of iliac arteries. Critical limb ischemia was successfully treated in all patients. One patient died after aortobifemoral bypass surgery; no fatal outcomes were registered after hybrid procedures.

Comparison between Aorto-bifemoral Bypass and Aorto-iliac Kissing Stent in Patients with Complex Aorto-iliac Obstructive Disease

s 401 evaluated the results in patients treated by hybrid and traditional surgery in order to establish if these procedures could be considered as the first choice. Methods: We performed a retrospective study analyzing a frame time of 13 years in order to identify patients with iliac femoral atheromatous disease (TASC II C/D). Primary end points have been considered the primary patency rate, limb savage and survival rate. Secondary end points such as secondary assisted patency, re-interventions and complications rate. Results: We identified 178 limbs in 168 patients (100 vs. 78 limbs treated respectively with Open and Hybrid approach). In the Hybrid group 86% of the patients were classified as ASA III/IV vs. 31% in Open group. Median age was 68 vs. 75 respectively per open and hybrid group. Indication for hybrid procedures was given in 93 limbs but after an accurate pre-operative study with Angio-CT scan we excluded 15 limbs due heavy calcification in 13 patients classified as ASA III/IV that underwent to extraanatomic repair. The technical success was 91.7% vs.100% (Open versus Hybrid). Primary patency in Open vs. Hybrid group at 1, 5 years was respectively 98%,99% vs. 7.5%,96.1%, assisted patency at 1, 5 years 99%, 98% vs. 98.7%, 97.5%, limb salvage at 1, 5 years 99%,98% vs. 96%,93.5%. 30 days mortality and at 1, 5 years were 5.6% e 28.4% vs. 1.2% e 25.6% Open vs. Hybrid group. Similar post-operative complications rate (6%) were observed in both groups, but 8.1% of open group needed admission intensive unit care. Conclusion: Hybrid procedures offered good results in terms of patency and limb salvage rate and with a low 30 mortality in patients classified at high risk for surgery. Similar survival rates between the 2 groups despite the high co-morbidities and older age that characterized the Hybrid group. Considering the good results the hybrid procedures could be considered as the first choice, but in some patients the anatomic arterial features remain the main limitation that still need traditional repair. Comparison between Aorto-bifemoral Bypass and Aorto-iliac Kissing Stent in Patients with Complex Aorto-iliac Obstructive Disease W. Dorigo , G. Piffaretti , F. Benedetto , R. Pulli , P. Castelli , F. Spinelli , C. Pratesi 1 1 Dept. of Vascular Surgery, University of Florence, Italy 2 Dept. of Vascular Surgery, University of Varese, Italy 3 Dept. of Vascular Surgery, University of Messina, Italy Introduction: To retrospectively compare early and late results of aortobifemoral bypass and endovascular recanalization with the kissing stent technique in the management of TASC II C and D lesions in the aorto-iliac district in a multicentre study. Methods: From January 2006 to December 2013, 293 open and endovascular interventions for TASC-II class C and D aorto-iliac obstructive lesions were performed at three Italian teaching hospitals. In 210 patients the intervention was performed for aortic and bilateral iliac involvement: an aorto-bifemoral bypass was performed in 82 patients (Group 1) while in the remaining 128 an endovascular recanalization with the kissing stent technique (Group 2). Early results in the two groups were compared with c test. Follow up results were analyzed with Kaplan-Meyer curves and compared with log rank test. Results: There were no differences between the two groups in terms of demographic data, comorbidities, or risk factors for atherosclerosis, except for a higher percentage of females and of diabetic patients in group 2. Critical limb ischemia was present in 29 patients in group 1 (35.5%) and in 31 patients in group 2 (24%, p 1⁄4 0.07). Technical success in group 2 was 98.5%; two patients required immediate conversion to open surgery for iliac rupture. There was one peri-operative death in group 1 (mortality rate 1.2%, p 1⁄4 0.2 in comparison with group 2). Four peri-operative thromboses occurred; two in group 1 and two in group 2 (in one case requiring conversion to open surgical intervention) and no amputations at 30 days were recorded. Post-operative local and systemic complications occurred in 20 patients in group 1 (24%) and in 13 patients in group 2 (10% p 1⁄4 0.006). Mean duration of follow up was 39 months (range 1 e108 months). Survival rates at 6 years were 65% (SE 0.07) in group 1 and 82% (SE 0.05) in group 2 (p1⁄4 0.07). At the same time interval, primary, assisted primary and secondary patency rates were similar; re-intervention rates were 6% in group 1 (SE 0.05) and 11% in group 2 (SE 0.04; p 1⁄4 0.2). Conclusion: Endovascular repair of complex aorto-iliac lesions with the kissing stent technique, in the multicentre experience, provided similar satisfactory early and late results to those obtained with open surgery, however with a lower rate of peri-operative complications and a trend towards better long-term survival. Long Term Outcomes of Common Femoral Artery Endovascular Repair A. Kaladji, P.-A. Vent, P. Chaillou, A. Costargent, T. Quillard, Y. Goueffic

Medico-economic Survey of the Learning Curve of the Treatment of Occlusive Aorto Iliac Lesions by Robotic Surgery

Medico-economic Survey of the Learning Curve of the Treatment of Occlusive Aorto Iliac Lesions by Robotic Surgery

Classification Systems for Lower Extremity Occlusive Disease

The management of lower extremity occlusive disease involves some of the most complex decision making in the field of vascular surgery. Patients with lower extremity occlusive disease often present with a wide spectrum of clinical manifestations ranging from mild intermittent claudication to severe ischemia with gangrene. Moreover, the prognosis and clinical management are dependent on the location and extent of the atherosclerotic disease burden, the presence of comorbid conditions that affect life expectancy and procedural patency, the revascularization options available, and the functional status of the patient. In an effort to bring order to this challenging disease, a number of lower extremity classification systems have been developed. This review discusses challenges of establishing a classification system, anatomic classification systems, classification systems based on presenting symptoms/clinical presentation, morbidity/mortality risk stratification systems, and disability classification systems. Tables outline the Society for Vascular Surgery runoff score, clinical categories of acute limb ischemia, Rutherford clinical categories of chronic limb ischemia, Fontaine clinical stages of chronic limb ischemia, LEGS (Lower Extremity Grading System) score used to recommend invasive treatment for patients with chronic lower extremity ischemia, WIfI (Wound Ischemia foot Infection) classification system grades, consensus estimate of 1 year amputation risk and likelihood of benefit of/requirement for revascularization based on WIfI spectrum score, predicted and observed 1-year outcomes (limb amputation, wound nonhealing) based on WIfI clinical stage classification, morbidity and mortality risk stratification methods, US social security administration disability criteria for patients with lower extremity occlusive disease and amputation, and criteria for rating impairment due to lower extremity peripheral vascular disease. Figures illustrate the TransAtlantic Inter-Society Consensus classification of aortoiliac and femoropopliteal lesions and Graziani System classes of progressive vascular disease severity and distribution in patients with diabetes mellitus presenting with foot wounds. This review contains 3 figures, 11 tables, and 35 references.

24-Month Data from the BRAVISSIMO: A Large-Scale Prospective Registry on Iliac Stenting for TASC A & B and TASC C & D Lesions

To evaluate the 24-month outcome of stenting in Trans-Atlantic Inter-Society Consensus (TASC) A & B and TASC C & D iliac lesions in a controlled setting. The BRAVISSIMO study is a prospective, nonrandomized, multicenter, multinational, monitored registry including 325 patients with aortoiliac lesions. The end point is the primary patency at 24months, defined as a target lesion without a hemodynamically significant stenosis on duplex ultrasound (>50%, systolic velocity ratio >2.0). A separate analysis for TASC A & B versus TASC C & D population is performed. Between July 2009 and September 2010, 190 patients with TASC A or B and 135 patients with TASC C or D aortoiliac lesions were included. The demographic data were comparable for TASC A & B cohort and TASC C & D cohort. Technical success was 100%. Significantly more balloon-expandable stents were deployed in TASC A & B lesions, and considerably more self-expanding stents were placed in TASC C & D (P=0.01). The 24-month primary patency rate after 24months for the total population was 87.9% (88.0% for TASC A, 88.5% for TASC B, 91.9% for TASC C, and 84.8% for TASC D). No statistically significant difference was shown when comparing these groups. The 24-month primary patency rates were 92.1% for patients treated with the self-expanding stent, 85.2% for patients treated with the balloon-expandable stent, and 75.3% for patients treated with a combination of both stents (P=0.06). Univariate and multivariable regression analyses using Cox proportional hazards model identified only kissing stent configuration (P=0.0012) and obesity (P=0.0109) as independent predictors of restenosis (primary patency failure). Interestingly, as all TASC groups enjoyed high levels of patency, neither TASC category nor lesion length was predictive of restenosis. The 24-month data from this large, prospective, multicenter study confirm that endovascular therapy may be considered the preferred first-line treatment option of iliac lesions, irrespectively of TASC lesion category.

Long-Term Results of Combined Aortoiliac and Infrainguinal Arterial Reconstruction for the Treatment of Critical Limb Ischemia

This study was designed to investigate our long-term experience with combined iliac endovascular therapy (EVT) and infrainguinal bypass to treat critical limb ischemia (CLI) and compare outcomes to those of patients who underwent surgery for aortoiliac lesions. From April 2000 to June 2013, 57 patients (58 limbs) underwent an infrainguinal bypass combined with aortoiliac reconstruction to treat CLI. Eighteen limbs were treated by bypass alone and 8 limbs were treated by bypass with EVT for aortoiliac lesions (Bypass group). Thirty-two limbs were subjected to EVT alone for iliac lesions (EVT group). Preoperative limb ischemia was more severe in the EVT group. There were no significant differences in major procedure-related complications (χ(2) test, P = 0.853), systemic complications (P = 0.853), and mortality (P = 0.916) between the 2 groups. The limb salvage rates were 92% at 1, 3, and 5 years in the Bypass group and 93% at 1, 3, and 5 years in the EVT group, with no significant difference observed between the groups (Kaplan-Meier, log-rank test, P = 0.616). Infrainguinal surgical reconstruction combined with an iliac EVT is an acceptable strategy for managing patients with CLI.

Valve-Like and Protruding Calcified Intimal Flap Complicating Common Iliac Arteries Kissing Stenting.

Endovascular therapy for iliac artery chronic total occlusions is nowadays associated with low rates of procedure-related complications and improved clinical outcomes, and it is predominantly used as first-line therapy prior to aortobifemoral bypass grafting. Herein, we describe the case of a patient presenting with an ischemic left foot digit ulcer and suffering complex aortoiliac lesions, who received common iliac arteries kissing stents, illustrating at final antegrade and retrograde angiograms the early recognition of a blood flow obstructing valve-like calcified intimal flap protruding through the stent struts, which was obstructing antegrade but not retrograde unilateral iliac arterial axis blood flow. The problem was resolved by reconstructing the aortic bifurcation at a more proximal level. Completion angiogram verified normal patency of aorta and iliac vessels. Additionally, a severe left femoral bifurcation stenosis was also corrected by endarterectomy-arterioplasty with a bovine patch. Postintervention ankle brachial pressure indices were significantly improved. At the 6-month and 2-year follow-up, normal peripheral pulses were still reported without intermittent claudication suggesting the durability of the procedure. Through stent-protruding calcified intimal flap, is a very rare, but existing source of antegrade blood flow obstruction after common iliac arteries kissing stents.

The association between periprocedural factors and the late outcome of percutaneous stenting of lower extremity arteries. A retrospective cohort study.

IntroductionAbout 20–30% of the population have peripheral artery disease. Many of them require intervention, with a percutaneous procedure currently being the first choice. However, the outcomes of these interventions need regular evaluation due to continuous progress in endovascular techniques and the devices used.AimThe aim of this study was to analyze procedural factors influencing the outcome of endovascular intervention in patients stented for the first time due to lower extremity atherosclerosis.Material and methodsThe medical documentation of 91 patients with at least 1 year of follow-up after stenting of a lower limb artery was retrospectively evaluated. Uni- and multivariate analyses were performed.ResultsThe mean observation time was 544.4 ±502.9 days. The primary patency of a stent after such a follow-up was 68.1%. Cox proportional hazard analysis revealed that the risk of target lesion revascularization was affected by the following (hazard risk, 95% confidence interval): the number of vascular segments with significant lesions (13.14, 2.28–75.8); critical limb ischemia (5.68, 1.23–26.2); localization of the target lesion in an aorto-iliac in comparison with a femoro-popliteal vascular segment (0.37, 0.14–0.7); aorto-iliac lesion class according to the TASC-II consensus (1.96, 1.1–3.8); and claudication distance (1.02, 1.01–1.03).ConclusionsThe common primary patency of a stent implanted into either an aorto-iliac or a femoro-popliteal vascular segment was similar to that found in other reports. The main factors affecting the outcome of the endovascular procedures performed were mainly related to atherosclerosis severity, not to the type of technique or device used.

Management of critical lower limb ischemia in endovascular era: experience from 511 patients.

This study aims at the assessment of the achievability of the endovascular treatment of patients with critical limb ischemia (CLI) and the role of bypass in such patient. This is a prospective study conducted on patients with chronic atherosclerotic critical lower limb ischemia presenting to us over a period of 3 years. Patients presenting with nonsalvageable limbs requiring primary major amputation and nonatherosclerotic causes of CLI were excluded. Endovascular treatment was the first choice modality of treatment in revascularization of all patients. Open surgery was offered selectively for patient whom endovascular failed or complicated and for long TransAtlantic Inter-Society Consensus (TASC) II lesions in fit patients. This study included 511 cases of CLI, and the mean age was 64.5 years. Patients with Rutherford IV, V, and VI were 19.25, 60.5, and 19.25%, respectively. The TASC II aortoiliac lesions were as follows: A, B, C, and D in 33.7, 12,15.7, and 38.6%, respectively, and infrainguinal lesions were A, B, C, and D in 3.7, 19, 35.4, and 68.3%, respectively. A total of 78.3% of patients were treated by endovascular totally, while 16% were treated by surgery from the start, 3.7% of endovascular cases were converted to open surgery after failure of endovascular treatment, and 2% was offered hybrid treatment. Crossing of lesions by subintimal and intraluminal was 12.5 and 87.5%, respectively. Technical success in endovascular was 94%; however, we could successfully revascularize 96.8% of all CLI presented in this study by either surgery or endovascular. On 24 months follow-up, primary patency, secondary patency, and limb salvage by percutaneous transluminal angioplasty are 77.8, 84.7, and 90.7%, respectively. Revascularization by endovascular achieves high technical success and limb salvage in CLI, hence should be considered as preferred choice of treatment. However, both endovascular and surgery should not be counteracting each other and using both can revascularize 96.6% of CLI.

VESS22. 24-Month Data From the BRAVISSIMO: A Large Scale Prospective Trial on Self-Expanding and Balloon-Expandable Stents for TASC A and B and TASC C and D Aortoiliac Lesions

Objectives: We assessed the effects of thoracic endovascular aortic repair (TEVAR) rehearsal with an endovascular surgical simulator in surgical trainees at different levels in training. Methods: Twelve trainees in three cohorts (student, postgraduate year [PGY]1-3, and PGY 4-7) were oriented to using the Simbionix AngioMentor simulator over four sessions. Likert scale qualitative analysis evaluated participant proficiency. Analysis of data included one-way analysis of variance and paired t-tests. Results: All groups had reduction of total procedure time (mean 537 6 148 seconds vs 269 6 66 seconds, first session vs fourth; confidence interval [CI], 195-341 seconds; P < .05) and fluoroscopy time (201 6 74 vs 110 6 37 seconds; CI, 51-132 seconds; P < .05) with case progression. Procedure time significantly decreased in students (551 6 84 vs 313 6 65 seconds; CI 189-287 seconds; P < .05) and PGY 1-3 (591 6 149 vs 264 6 29 seconds; CI, 113541 seconds;P< .02) had a significant decrease in procedure time. Fluoroscopy times were brief overall between individuals and groups and did not change significantly with case progression. Participants acquired proficiency after a few runs in almost every step of the procedure. Endograft sizing appeared to be the most challenging task by qualitative analysis. PGY 4-7 trainees had higher technical scores, but this was not statistically significant. Conclusions: Practice on endovascular surgical simulators can reduce overall procedure and fluoroscopy time, independent of trainee skill level or experience. Endovascular simulators can be effective tools in residency training and maintenance of proficiency. Further studies are needed to compare simulator performance with outcomes in real cases.

Role of the latest endovascular technology in the treatment of intermittent claudication.

Intermittent claudication is a serious symptom in patients with peripheral arterial disease, and severely limits activities of daily living. Conservative treatment (optimal medical therapy and exercise rehabilitation programs) and revascularization procedures (endovascular treatment [EVT] or open bypass surgery) can relieve intermittent claudication. Among these treatment options, EVT has developed dramatically during the past decade, and has enabled physicians to offer less invasive treatment options with increasing durability. EVT for aortoiliac lesions has matured, and its long-term patency now approaches that of open bypass surgery. The latest EVT technologies include drug-eluting stents, stent grafts, drug-coated balloons, and bioresorbable stents. The recently reported patency of stent grafts in the femoropopliteal lesions was comparable with that of the prosthetic bypass graft. In the course of the paradigm shift from bypass surgery to EVT, evidence of any long-term benefit of EVT compared with supervised exercise is still inconclusive. EVT could improve walking performance in the short-term, while supervised exercise could improve walking performance more efficiently in the long-term. Combined treatment with EVT and exercise may offer the most sustainable and effective symptom relief. This paper reviews the relevant literature on the treatment of intermittent claudication, focusing on the latest EVT technologies, and outlines a strategy for achieving long-term benefits.

Transbrachial and Femoral Artery Approach Endovascular Therapy for Flush Infrarenal Aortic Occlusion

The purpose of this study is to report the efficacy of transbrachial and femoral artery approach endovascular therapy with catheter-directed thrombolysis (CDT) and adjunctive therapy for flush infrarenal aortic occlusion (FIAO). From March 2012 to December 2013, 11 consecutive patients (9 males; mean age 68 years; range 54-80 years) were submitted to endovascular therapy for FIAO. All patients were treated with CDT initially and then adjunctive endovascular treatments were performed to correct the underlying lesions. Complete reconstruction of occluded aortoiliac arteries was successfully achieved in 81.8% (9/11) of patients. Left brachial and bilateral femoral arterial accesses were obtained in nine patients, and brachial and unilateral femoral in two patients. The residual lesions after CDT were corrected in nine patients and concomitant endovascular recanalization of superficial femoral artery was performed in two patients. Self-expandable stents were implanted in the all aortoiliac lesions with pre- and post-dilation. No renal or distal runoff embolization was seen during intraoperative angiography. Seven (7/9) patients with rest pain or tissue loss showed significant improvements in symptoms and two (2/9) patients with intermittent claudication gained an improved walking distance. The ABI rose significantly between pre- and post-procedure (0.84 ± 0.18 vs. 0.44 ± 0.13 on the right leg, p < .01; 0.89 ± 0.23 vs. 0.48 ± 0.16 on the left, p < .01). Transbrachial and femoral artery approach endovascular therapy for FIAO offers an alternative to surgical reconstruction with immediate outcomes.