Aortoiliac Revascularization Research Articles

Outcomes of Total Aortoiliac Revascularization for TASC-II C&D Lesion with Kissing Self-Expanding Covered Stents

The endovascular approach has been widely used for aortoiliac occlusive disease (AIOD), especially for aortic bifurcation and iliac artery Trans-Atlantic Inter-Society Consensus II (TASC-II) A and B lesions. However, the outcomes of self-expanding covered stents (SECSs) for extensive aortoiliac lesion remain unclear. This study aimed to assess the short-term patency of kissing covered stents for the revascularization of aortoiliac TASC-II C and D diseases. Thirty-three patients with TASC-II C and D lesions of AIOD were treated with kissing covered stents. All patients were reviewed under a standard institutional review board protocol. Demographic variables, lesion location and characteristics, stenting configuration, and patency were analyzed. Thirty-one male and 2 female patients with a mean age of 65.1±10.7years underwent aortoiliac bifurcation reconstruction with kissing SECSs. Eight patients had TASC-II C lesions, and 25 patients had TASC-II D lesions. Among them, 8 patients had total infrarenal aortoiliac occlusion, of which 5 had juxtarenal aortoiliac lesions. The mean lesion length was 11.6±2.1cm. Mean diameters of aorta and common iliac artery were 18.3±2.1 and 10.7±1.5mm, respectively. Among them, the abutting stent configuration was used in 11 patients with short or focal ostial lesions, whereas the crossing stent configuration was used in 22 patients with longer lesions extending into the distal aorta. The mean follow-up was 24.5±7.8months, the follow-up rate was 93.9% (31 of 33), and 29 patients had follow-up longer than 12months. Primary patency rate at 12months was 96.5%, and secondary patency rate was 100%. The use of kissing SECSs for the revascularization of extensive AIOD is safe and effective. The short-term primary patency rates of endovascular treatment of TASC-II C and D lesions were favorable.

Predictors of serious morbidity and mortality after endovascular repair of aortoiliac lesions

BackgroundEndovascular approaches to aortoiliac disease are becoming increasingly frequent due to decreases in recovery time, bleeding, and discomfort. Despite this trend, little is known about the predictors of complications. This study was designed to identify risk factors for major 30-day morbidity and mortality after endovascular repair. MethodsData were derived from the 2015–2016 Participant User Files and Procedure Targeted databases of the American College of Surgeons National Surgical Quality Improvement Program. Demographics and comorbidities of patients undergoing repair were assessed. Preoperative risk factors were analyzed using univariate and multivariate analysis. ResultsTwelve hundred and nine patients underwent endovascular aortoiliac repair, including 532 females (44.0%) and 677 males (56.0%). The 30-day mortality rate was 0.7%. Diabetes mellitus requiring medication, chronic steroid use, dialysis, pre-existing open wound, age, and low serum albumin and hematocrit increased mortality. After logistic regression, 30-day mortality was correlated with low serum albumin (survivors = 3.77, nonsurvivors = 2.60; P = .003) and chronic steroid use (P = .020). Multivariate analysis identified high preoperative white blood cell count as a risk factor for amputation. Diabetes, smoking history, and low serum sodium were risk factors for return to the operating room. Female sex and steroid use were risk factors for myocardial infarction and stroke. Open wounds and high platelets were risk factors for the need for an operative bypass after endovascular intervention. Preprocedural statin use was protective against need for a later operative bypass and reintervention. ConclusionsOpen wound, smoking, preprocedural steroid use, diabetes, female sex, high platelet and white blood cell count, and low serum albumin are the most strongly associated risk factors for adverse 30-day postoperative outcomes. Mortality rates remain low after endovascular aortoiliac revascularization.

Results of hybrid procedures for treatment of aortoiliac Trans-Atlantic Inter-Society Consensus II D lesions with self-expanding covered heparin-bonded stent grafts.

According to the guidelines aortoiliac TASC D lesions should be treated by bypass. The purpose of this study was to examine the results of hybrid procedures with the use of a self-expanding covered heparin-bonded stent graft (Viabahn) in patients with extensive aorto-iliac lesions who were not considered to be suitable for open aorto-iliac surgery. All patients who received a hybrid procedure in combination with a Viabahn stent in our clinic to treat aortoiliac lesions between October 2011 and April 2017 were included in this retrospective analysis. Study endpoints were primary patency, amputation-free survival (AFS) and major adverse limb event (MALE) free survival after 2 years. We included 23 hybrid procedures (endarterectomy of the common femoral artery or cross over bypass and aortoiliac stent) in 20 patients (median age 59 years). Indication was critical limb ischemia in 70.0%. The reasons why patients were on high risk for alternative open aortoiliac revascularization were hostile abdomen in 35.0%, cardiopulmonary contraindications in 35%, cancer in 10.0%, age >80 years in 10.0% and alcoholic cirrhosis in 10.0%. The 30-day mortality was 15.0%, the major amputation rate was 4.3%. We had no early graft occlusion. After 2 years primary patency was 100%, AFS 58.2% and MALE free survival 95.7%. A hybrid procedure with the use of a Viabahn stent in severe aortoiliac pathologies showed good patency results in this selected patient group. Therefore, it should be considered a feasible alternative to aortoiliac bypass surgery in surgical high-risk patients.

The impact of inflow treatment for claudicants with both aortoiliac and femoropopliteal occlusive disease.

This study evaluated the early and long-term results of the sole use of endovascular treatment in the treatment of inflow lesions in claudicants with both aortoiliac and femoropopliteal (FP) lesions. A retrospective study that included 100 limbs in 73 patients was performed. The patency rates of aortoiliac artery stents, the continued clinical improvement rates, the risk factors for persistent disabling claudication after inflow revascularization, and the rates of freedom from additional FP procedures were examined. After inflow revascularization, almost complete relief from intermittent claudication was seen in 79% of the limbs, while 21% of the limbs continued to suffer from disabling claudication. A multivariate analysis showed that a run-off score of ≥7 was an independent predictor for persistent disabling claudication after aortoiliac revascularization [hazard ratio (HR) 5.11, 95% confidence interval (CI) 1.34-19.45; P=0.02]. The primary patency rates at 1, 3, 5, and 6years were 96, 96, 96 and 89%, respectively. The secondary patency rate at 6years was 100%. The continued clinical improvement rates at 1, 3, 5, and 6years were 81, 78, 78 and 72%, respectively. The rates of freedom from additional FP procedures at 1, 3, 5, and 6years were 97, 90, 90, and 90%, respectively. Aortoiliac endovascular revascularization is effective treating claudicants with both aortoiliac and femoropopliteal lesions. Furthermore, a run-off score of ≥7 appears to be a potential predictor for persistent disabling claudication.

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

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.

Cost analysis of vascular readmissions after common vascular procedures

This study analyzed readmissions and their associated hospital costs after common vascular surgeries at a single institution. Patients undergoing open or endovascular abdominal aortic aneurysm repair, aortoiliac revascularization, or infrainguinal revascularization, from 2010 through 2012, were retrospectively evaluated. We compared 30- and 90-day readmission rates and costs by procedure group, and we tabulated reasons for readmission and procedures performed during readmission. We used both American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data and patient records; as NSQIP only captures 30-day data, we retrospectively reviewed patient charts to extend the evaluation to 90 days. Analyses were performed using parametric or nonparametric methods as appropriate. Two hundred nineteen cases were analyzed; the overall rate of index admission survivors experiencing at least one readmission within 30 days was 17% and within 90 days, 27%. Median readmission costs were $10,700, which added 39% to the median index costs of $27,700. Over half of readmissions (55%) included an operation. The most common cause for readmission was related to wound complications, comprising approximately 30% of the entire readmission cohort. Independent drivers of readmission costs were the need for additional surgical procedures, the use of intensive care unit services, and the number of days spent in the hospital above the median. Total 90-day costs were statistically equivalent between open and endovascular procedures when including readmissions. We found that vascular surgery readmissions occur at a rate of 17% at 30 days and 27% at 90 days. When including the costs of readmission for a wide variety of common vascular cases, there is no significant difference in total costs between endovascular and open procedures at 90 days.

FT1. Utility of Intraoperative Cone Beam Computed Tomography in Endovascular Treatment of Aortoiliac Occlusive Disease

Endovascular treatment of aortoiliac occlusive disease (AIOD) is well established, but secondary interventions are not uncommon to maintain long-term patency. Multiple stents and iliac artery tortuosity often make it difficult to evaluate stent compressions intraoperatively, and this might be a cause for later failure. Completion angiogram (CA) and pressure gradient (PG) measurement are often used to control the final intraoperative result. The purpose for this study was to evaluate the intraoperative outcome by cone beam computed tomography (CBCT) in order to optimize the primary operation results. Fifty-three patients (28 females) were enrolled in a prospective study. All patients underwent aortoiliac revascularization. Final intraoperative results were evaluated with additional CBCT after CA and PG were found satisfactory. Imaging findings and imaging-based adjunctive procedures were recorded. A total of 165 stents were placed due to AIOD. Twenty-six of 53 patients had kissing stents were placed in the aortoiliac bifurcation. Twenty-one patients underwent adjunctive procedures after the primary stenting. In 24.5% (13 of 53) cases, adjunctive procedures were indicated solely by the CBCT findings, because both standard CA and PG were normal. Adjunctive procedures were needed in 38.5% of the kissing stent patients, and in six of 10, 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. Particularly in patients receiving kissing stents, CBCT seemed to be beneficial. In this study, CBCT improved the technical results intraoperatively, which might influence the long-term patency positively.

Hybrid Aortoiliac Revascularization to Avoid Nonautogenous Groin Reconstruction in an Intravenous Drug Abuser

Traditional methods for revascularization of an occluded aortoiliac system have necessitated either in-line aortic reconstruction through an aortobifemoral bypass or extra-anatomic bypass. However, both these approaches require artificial material to be placed in the groin. The consequence of groin infection can be devastating leading to high rates of both limb loss and mortality. One of the most feared patient populations presenting with groin complications is that of the intravenous drug abuser. We present the case of a patient with a long history of intravenous drug abuse with severe aortoiliac disease. Instead of resorting to a more traditional open surgical approach necessitating artificial reconstruction in the groin, we chose to proceed with a hybrid open and endovascular procedure through a direct open surgical access to the aortic bifurcation. This allowed for revascularization without the placement of artificial material in the groin.

Design of the multicenter standardized supervised exercise training intervention for the ‘CLaudication: Exercise Vs Endoluminal Revascularization (CLEVER) study’

The CLaudication: Exercise Vs Endoluminal Revascularization (CLEVER) study is the first randomized, controlled, clinical, multicenter trial that is evaluating a supervised exercise program compared with revascularization procedures to treat claudication. In this report, the methods and dissemination techniques of the supervised exercise training intervention are described. A total of 217 participants are being recruited and randomized to one of three arms: (1) optimal medical care; (2) aortoiliac revascularization with stent; or (3) supervised exercise training. Of the enrolled patients, 84 will receive supervised exercise therapy. Supervised exercise will be administered according to a protocol designed by a central CLEVER exercise training committee based on validated methods previously used in single center randomized control trials. The protocol will be implemented at each site by an exercise committee member using training methods developed and standardized by the exercise training committee. The exercise training committee reviews progress and compliance with the protocol of each participant weekly. In conclusion, a multicenter approach to disseminate the supervised exercise training technique and to evaluate its efficacy, safety and cost-effectiveness for patients with claudication due to peripheral arterial disease (PAD) is being evaluated for the first time in CLEVER. The CLEVER study will further establish the role of supervised exercise training in the treatment of claudication resulting from PAD and provide standardized methods for use of supervised exercise training in future PAD clinical trials as well as in clinical practice.

Periphere arterielle Verschlusskrankheit und akute Extremitätenischämie

In this article, current evidence-based treatment recommendations for acute and chronic lower limb ischemia will be presented considering the varied possibilities of endovascular techniques and open surgical vascular strategies. Beside presentation of the different therapeutic possibilities, advantages of the combination of both techniques will be described. Despite the BASIL trial, there are no prospective randomised controlled trials comparing endovascular and open surgical interventions. Different therapeutic rules along the different vascular segments will be discussed for both acute and chronic peripheral arterial disease. Generally it can be stated that aortoiliac revascularization for chronic obstructions is increasingly being carried out by endovascular means or hybrid procedures using a minimally invasive femoral approach, whereas acute occlusions in this vascular segment are still treated with open surgical techniques (Fogarty balloon thrombectomy). In the infrainguinal region, endovascular therapeutic strategies are gaining favor. However, multilevel occlusions and long-segment obstructions in the femoral and popliteal segment are still treated by bypass procedures. Acute ischemia in the infrainguinal segment is increasingly treated with endovascular methods (local thrombolysis and percutaneous thrombectomy).

Thoracofemoral Bypass: A Useful Addition to a Vascular Surgeon's Armamentarium

Several alternative methods are available for aortoiliac revascularization when the standard approach is contraindicated or hazardous. In these circumstances, axillofemoral bypass is favored, but the long-term patency is inferior and is generally reserved for higher-risk patients. Better inflow with improvement in long-term results can be achieved using a more proximal aortic source from the supraceliac, or ascending or descending thoracic aorta. All of these alternatives provide excellent inflow and the patency rates are comparable. The final choice will depend upon the surgeon's personal preference. The descending thoracic aorta-to-femoral bypass is a useful technique in selected, younger, low-risk vascular patients. It is a valuable option when the transabdominal approach to the infrarenal aorta is difficult, such as after prior removal of an infected aortic graft. Relative indications include multiple previous laparotomies or multiple aortic reoperations, a densely scarred retroperitoneum, or heavy calcification or ectasia of the abdominal aorta.

Angioplasty balloons, stents, and endografts

When Charles Dotter described the first angioplasty in 1964, his vision of the potential for the procedure far exceeded the materials and devices available to achieve his lofty goals. This first angioplasty, performed with coaxial catheters rather than an angioplasty balloon, paved the way for the technical and medical revolution that has occurred in the management of peripheral vascular disease (PVD) over the past 30 years. Percutaneous interventions have been proven effective and durable. Among the most impressive results are those achieved in the iliac system. This success has in large part been related to the great technical advances that occurred in balloon catheter and stent technology over the past 25 years. This article reviews the important properties of balloons and stents as they apply to clinical applications in aortoiliac revascularization. In addition, a brief review of stent-grafts is presented.

Presidential address: Practice patterns in vascular surgery—Implications for the certification and training of vascular surgeons

It is a privilege for me to welcome you to the Eleventh Annual Meeting of the Eastern Vascular Society (EVS). Serving as President of your Society during this past year has been a great pleasure and distinct honor for me. As I contemplated the traditional obligation for this address, I was impressed with the emergence of our specialty of vascular surgery to a position of independence, as well as the gravity of decisions and crossroads we face movingtoward the next century. Today, I have chosen to review a body of data that impacts on the practice of vascular surgery and the training of vascular surgeons. In preparing for this presentation, I have used data previously collected for the Association of Program Directors in Vascular Surgery (APDVS; Manpower survey. Hobson RW, unpublished data; 199596.). I have been urged by many colleagues to publish this information, and I trust that it will interest you as well as constitute a useful review for those of you in the audience who attended recent meetings of the APDVS. In my opinion, these data reflect ongoing changes in the practice of vascular surgery and have important implications for the certification and future training of vascular surgeons.

Exercise-Induced Urinary and Fecal Incontinence: An Exceedingly Unusual Presentation of Aortoiliac Occlusive Disease

Fecal and urinary incontinence is an exceedingly unusual manifestation of aortoiliac occlusive disease, with only 4 previous cases having been reported in the literature. The authors report the case of a sixty-two-year-old woman with a long history of bilateral lower extremity claudication and exercise-induced urinary and fecal incontinence. Angiography demonstrated a complete infrarenal aortic occlusion. Following aortofemoral bypass, peripheral perfusion normalized and the patient experienced complete relief of claudication and incontinence. The authors propose that the patient's incontinence was due to intermittent pelvic ischemia as a consequence of her aortoiliac disease. In contrast to the cauda equina syndrome, a “steal” mechanism is the most likely explanation for the pathophysiology of exercise-induced pelvic ischemia, which may be completely eradicated by aortoiliac revascularization.

Aortoiliac reconstruction combined with nonvascular operations

Seventy-six patients with aortoiliac reconstruction and associated intraabdominal procedures were compared with 445 patients with aortoiliac revascularization alone to provide information about the associated morbidity and mortality of adding a nonvascular procedure to aortic reconstruction. Patients with aortoiliac reconstruction for limb salvage had a significant increase in complications when an abdominal procedure was performed in association with aortoiliac reconstruction (66 percent versus 14 percent, p < 0.01). Additionally, patients with elective aortoiliac reconstruction had a significant increase in mortality when an abdominal procedure was performed in addition to aortoiliac reconstruction (9 percent versus 3 percent, p < 0.01). A small bowel obstruction and a pancreatic pseudocyst occurred as a direct result of the associated abdominal procedure. None of the deaths could be directly attributed to a concomitant abdominal procedure. The demonstration of an increase in morbidity and mortality with the addition of nonvascular procedures to aortoiliac reconstruction, even though certain subgroups of patients underwent aortic revascularization, suggest that the surgeon must carefully weigh the benefits and risks before combining vascular and nonvascular operations.

Elimination of Iatrogenic Impotence and Improvement of Sexual Function After Aortoiliac Revascularization

Elimination of Iatrogenic Impotence and Improvement of Sexual Function After Aortoiliac Revascularization

Elimination of iatrogenic impotence and improvement of sexual function after aortoiliac revascularization.

One hundred ten men who underwent revascularization for aortoiliac occlusive disease by either aortic reconstruction (n = 66), crossover femorofemoral bypass (n = 38), or axillofemoral bypass (n = 6) were examined with regard to preoperative and postoperative sexual function. Aortic reconstructions were performed using a nerve-sparing technique, and special emphasis was placed on preservation or improvement of pelvic blood supply. Thirty patients (27%) were impotent preoperatively and postoperatively, 67 patients (61%) had normal sexual function preoperatively and postoperatively, and 13 patients (12%) who were impotent preoperatively regained sexual function as a result of revascularization, indicating that 30% (13/43) of all patients with preoperative impotence regained sexual function. No patient with normal preoperative sexual function was impotent postoperatively. Nerve-sparing aortic dissections, attention to preservation or improvement of pelvic blood flow, and, when appropriate, extra-anatomic bypass are essential in the preservation or improvement of sexual function after aortoiliac revascularization.