Iliac Artery Chronic Total Occlusions Research Articles

Combining transradial access and sheathless femoral access for complex iliac artery chronic total occlusions

BackgroundThe transradial approach (TRA) is associated with fewer serious access site-related complications compared with the transfemoral or transbrachial approach. However, TRA has associated problems in complex aortoiliac (AI) lesions, including the procedural difficulty. A bidirectional approach was used combining TRA with a sheathless technique for femoral artery (FA) puncture to treat complex AI lesions, as a minimally-invasive approach. This report describes a representative cases with AI chronic total occlusion in which the combination of TRA and a sheathless technique for FA puncture was useful for guidewire crossing.Case presentationCase 1 was a 71-year-old man with intermittent claudication (IC). Control angiography showed total occlusion of the left common iliac artery (CIA) ostium to the distal external iliac artery (EIA). Guidewire externalization was achieved by combining TRA using a 6Fr guiding sheath and a sheathless technique for the left FA. Two nitinol stents were deployed in the CIA to EIA. Case 2 was a 63-year-old man with IC. Control angiography revealed total occlusion of the right CIA ostium to the common femoral artery (CFA) with severe calcification. The antegrade wire could not pass through the CTO lesion because of the calcified CFA occlusion. A 21-G metal needle was used to penetrate the CFA calcification through the distal true lumen of the CFA, and the wire was inserted into the EIA for wire externalization. Three nitinol stents were deployed in the CIA to EIA, and a drug-coated balloon was dilated in the CFA with hemostasis of the distal puncture site. In both cases, the retrograde puncture site was hemostatic during the procedure and postoperative bed rest was not required.ConclusionsTRA combined with a sheathless technique from the FA has the potential to treat AI complex lesions in a less invasive manner.

Effectiveness and long-term outcomes of different crossing strategies for the endovascular treatment of iliac artery chronic Total occlusions

BackgroundThe iliac occlusive disease is usually treated with endovascular procedures in recent years. The effectiveness of different crossing approaches for these occlusions is not precisely known. We performed a retrospective study to explore the optimal crossing approach (antegrade versus retrograde) for iliac artery chronic total occlusions (CTOs) and to examine the long-term outcomes.Materials and methodsWe performed a study on 107 patients (116 iliac occlusive lesions, mean age 64.0 ± 11.1, 88 men) who underwent an iliac CTO endovascular intervention attempted with the use of both crossing strategies but were managed with one final crossing approach between August 2012 and August 2018. Baseline data, procedural characteristics, and outcomes were described. A Cox proportional hazard model and Kaplan-Meier method were developed to assess the differences in the two crossing approaches in terms of the 1-year and 5-year primary patency rates, target lesion revascularization (TLR) and major adverse limb events (MALEs).ResultsCommon iliac artery (CIA) lesions were more likely to be crossed successfully in the retrograde direction (6.8% for antegrade vs. 20.9% for retrograde, p = 0.005), while lesions in the CIA/ external iliac artery (EIA) were more prone to be crossed successfully in the antegrade direction (58.9% for antegrade vs. 39.5% for retrograde, p = 0.016). There were no significant differences in the crossing approach for EIA lesions between the two groups. The two crossing approaches were associated with similar estimates of 1- and 5-year primary patency, TLR and MALE rates.ConclusionThe antegrade approach was associated with a higher rate of successful crossing in CIA/EIA CTO lesions, while the CIA-only CTOs were more likely to be crossed successfully with the retrograde approach.

Radial Plus Ipsilateral Femoral Approach is Feasible in Percutaneous Interventions for Iliac Artery Chronic Total Occlusion

Compared with conventional bilateral femoral (BF) approach, radial plus ipsilateral femoral (RF) approach may be feasible in the percutaneous intervention for iliac artery chronic total occlusion (CTO). We included patients who underwent iliac CTO intervention between August 2009 and July 2018 in a tertiary referral center in Korea. A total of 83 patients were enrolled in this study. Of them, 51 and 32 patients were categorized into RF and BF initial access groups, respectively. The overall success rates were 98.0% and 96.7% in RF and BF group, respectively, and the techniques were also similar including use of bilateral wiring, stent type and profile, and post balloon but longer procedure time in the BF group. Additional contralateral femoral access was needed in 6 patients for the treatment of contralateral lesions, distal embolization, and due to tortuous right subclavian artery. Periprocedural complications including vascular injury, iliac perforation, and distal embolization occurred similarly in both groups with numerically lower rate of periprocedural bleeding in the RF group (9.8%) than in the BF group (21.9%). Clinical follow-up at 6months showed there were no difference in the rates of death, cardiovascular death, target-limb reintervention, and unplanned target limb amputation in both groups. RF approach for iliac CTO intervention was related to similar technical success rate with acceptable periprocedural safety outcomes compared with conventional BF approach.

Treatment of an external iliac artery chronic total occlusion using alternate access sites

BackgroundWith the advent of endovascular techniques, alternate sites such as the pedal and radial arteries can now be accessed when treating peripheral arterial disease to reduce procedural complications, shorten recovery time, and improve patient comfort. However, a paucity of literature exists on the availability of support devices that can be utilized during challenging cases.Case presentationA 70 year-old female patient presented for evaluation of severe lifestyle-limiting left-sided claudication refractory to maximal medical therapy. Angiography revealed a chronic total occlusion of the left external iliac artery, which was treated successfully by percutaneous intervention via a primary transpedal approach and with the assistance of the Outback® Elite re-entry device. The patient was discharged 2 h after the procedure and reported significant symptom improvement at follow-up.ConclusionThis case highlights a newly adopted endovascular approach through an alternate access site and illustrates how the Outback® Elite device can be used as an adjunctive tool in the treatment of complex lower-extremity vascular lesions.

Use, Safety and Effectiveness of Subintimal Angioplasty and Re-Entry Devices for the Treatment of Iliac Artery Chronic Total Occlusions: A Systematic Review of 30 Studies and 1112 Lesions

Management of iliac artery occlusive disease has changed dramatically over the past few decades. Secondary to advancement in endovascular technologies and techniques, percutaneous interventions have gradually replaced open surgical approaches even for the most difficult cases. In difficult to cross chronic total occlusions (CTO) of the iliac artery, subintimal angioplasty (SIA) with or without the use of re-entry devices (RED) offers a valuable alternative to intra-luminal crossing. To systematically review the literature for studies reporting procedural or short- and long-term clinical outcomes after the use of SIA, with or without RED use for iliac CTOs. PRISMA guidelines were followed. Literature search (PubMed, Cochrane CENTRAL and EMBASE) and data extraction were performed by two independent researchers. Quantitative synthesis of the reported outcomes was applied when possible. Thirty studies met the inclusion criteria and were selected as eligible for this systematic review, with a total of 1002 patients (61.3% males) and 1112 lesions treated with SIA. RED were used in 21.9% of the lesions. Critical limb ischemia was the indication in 51.4%. The overall procedural success rates were 85.8% for SIA and 88.5% for RED. The complication rate ranged from 0 to 10% among different series, but overall it was similar among the two groups (6.9% in the RED group and 6.7% among the SIA group). One year primary patency rates were around 60% in the RED. In the SIA only arm, there was a large heterogeneity, with patency rates ranging from 51.7% to 96.8%. SIA with or without RED use is a safe and effective treatment for the treatment of iliac artery CTOs. Future studies are needed to delineate whether intraluminal crossing or SIA is more effective for endovascular treatment of iliac CTOs.

Acute and Midterm Outcomes of Antegrade vs Retrograde Crossing Strategies for Endovascular Treatment of Iliac Artery Chronic Total Occlusions

Purpose: To examine whether an antegrade or retrograde crossing strategy for treatment of iliac artery chronic total occlusions (CTOs) is associated with differences in procedural or midterm outcomes. Materials and Methods: A dual-center retrospective cohort study was conducted in 168 patients (mean age 66.4±10.6 years; 116 men) treated for CTOs in 110 common iliac arteries (CIA), 52 external iliac arteries (EIA), and 26 combined CIA/EIAs. Logistic regression models were developed to determine the association between crossing strategy and procedural complications, 1- and 3-year target lesion revascularization (TLR), and major adverse limb events (MALE). Results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: An initial antegrade strategy was more common for EIA CTOs (p<0.005), and an initial retrograde strategy was more often used in CIA (p<0.005) and combined CIA/EIA (p<0.005) CTOs. Crossover to an alternate approach was required in 27.6% of initial antegrade attempts and 9.6% of initial retrograde attempts. EIA CTOs were the most likely lesions to be treated successfully with the initial attempt (either strategy). In all, 123 (65.4%) lesions were successfully crossed with a final retrograde approach and 65 with a final antegrade approach. Overall target lesion success was high for both groups (95.1% vs 93.2%, p=0.456). Lesions treated with a final retrograde approach were shorter (75.3±34.9 vs 87.6±31.3 mm, p=0.005) and were more likely to be treated with a reentry device (34.2% vs 9.2%, p<0.001) and with balloon-expandable stents (39.2% vs 17.7%, p=0.005). The final antegrade approach was associated with a lower risk of target lesion complications (OR 0.07, 95% CI 0.01 to 0.81, p=0.034). The two crossing approaches were associated with similar estimates of 1- and 3-year TLR and MALE. Conclusion: A final antegrade approach was associated with lower rates for complications but the 2 approaches were similar in terms of lesion success, TLR, and MALE. The EIA CTOs were more likely to be treated with an antegrade approach and more likely to be crossed successfully with the initial approach irrespective of the crossing direction.

Distal Radial and Transpedal Access for Iliac Artery Chronic Total Occlusion Recanalisation using the Rendezvous Technique

Distal radial artery access with combination of the transpedal access has not been published in the literature for iliac artery chronic total artery occlusion (CTO) recanalisation. A 70-years-old male patient with critical limb ischaemia was presented for iliac artery CTO recanalisation. The distal radial artery was punctured by ultrasonography guidance and the anterograde recanalisation was started from radial artery access, but due to the failed reentry the retrograde recanalisation was done from transpedal access and the retrograde reentry was performed with Rendezvous-technique using dual balloon inflations. Iliac artery stent implantation was done from transpedal access using 6F slender sheath with the good angiography result.

Long-term outcomes after re-entry device use for recanalization of common iliac artery chronic total occlusions.

To examine the impact of re-entry device (RED) use on 1- and 5-year outcomes after endovascular treatment of common iliac artery (CIA) chronic total Occlusions (CTOs). There are not enough data regarding the long-term safety and efficacy of RED. We performed a two-center retrospective study of 115 patients (140 lesions) undergoing CIA CTO endovascular intervention between 2006 and 2016. Baseline characteristics and long-term outcomes were described. A Cox proportional hazard model was developed to determine if REDs were associated with target lesion revascularization (TLR) or major adverse limb events (MALE) after 1 and 5 years. Among 140 lesions, 43 (31%) required use of a RED. The mean age was 63.9 years and the majority (n = 80) of patients were male. An antegrade crossing approach and treatment of restenotic lesions were less common in the RED group (10% vs. 29%, P < .05 and 0% vs. 21%, P < .05, respectively). There were no significant differences in Rutherford class, pre-procedure ABI, or patient presentation. The procedural complication rates were similar between the two groups. The 1- and 5-year TLR rates for lesions treated with re-entry device vs. standard approaches were 11% vs. 9%; P = 0.8 and 29% vs. 29%; P = 0.9 respectively. The 1 and 5-year MALE rates for lesions treated with re-entry device were 5% vs. 6%; P = 0.8 and 11% vs. 11%; P = 0.9 respectively. This retrospective analysis found that recanalization of CIA occlusions using a RED is safe and is associated with long-term clinical outcomes similar to that of standard crossing techniques.

Novel Use of the “Contra Catheter” (CC) In Proximal Iliac Artery Chronic Total Occlusion (PICTO) Recanalization

Proximal Iliac Artery chronic total occlusion (PICTO) interventions via contralateral femoral approach are challenging due to the lack of catheter support. In patients with the appropriate anatomy, the Contra Catheter (CC) grasps the aortic bifurcation like a clip and can facilitate crossing of the occlusion. We describe three cases with PICTOs in which the CC was able to provide adequate support with a contralateral femoral approach and obviate the need for an arm approach.

OUTBACK catheter for treatment of superficial femoral and iliac artery chronic total occlusion: Experience from two centers.

Purpose:The OUTBACK® catheter is a reentry device that enables reentry into a vessel lumen from the subintimal space during subintimal angioplasty. It is reserved for cases where reentry has not been possible using conventional wire and catheter techniques. We report a two-center experience in recanalization of the chronic total occlusions of the common iliac (CIA) and the superficial femoral artery (SFA) using the OUTBACK® catheter in cases where other techniques were unsuccessful.Material and Methods:All cases where recanalization was performed using the OUTBACK® reentry catheter between January 2010 to January 2015 were retrospectively identified and included in this study. 21 patients were identified. The indication for intervention in these cases included claudication and critical leg ischemia. In all cases, conventional recanalization could not be successfully achieved.Results:The OUTBACK® catheter was used to recanalize 10 SFA occlusion and 9 CIA occlusions. In 19 patients (90%), reentry into true arterial lumen was successfully achieved. 17 patients had their recanalization through the transfemoral approach whereas 2 patients had a transpopliteal artery approach. In 2 patients, reentry into the true lumen could not be achieved using the OUTBACK® catheter due to patient's intolerability for the procedure and severe atherosclerotic calcified plaques. There was 100% patency of the vessel intervened on Duplex ultrasound at 24 months of follow up. 16 patients (84%) remained asymptomatic and 2 patients (10.5%) reported worsening of their symptoms due to the development of new lesions within the arterial system.Conclusion:The OUTBACK® catheter is an effective and safe technique for reentry into the vessel lumen when conventional techniques fail.

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.

Reentry Device Aided Endovascular Aneurysm Repair in Patients with Abdominal Aortic Aneurysm and Unilateral Iliac Artery Occlusion

We report 2 cases of patients undergoing endovascular aneurysm repair (EVAR) using reentry devices to recanalize unilateral iliac artery occlusions and complete a bifurcated endovascular repair. Patient 1 is a 70-year-old male with an enlarging 6.5-cm abdominal aortic aneurysm (AAA) and disabling left leg claudication with L external iliac occlusion with patent common and internal iliac arteries. Patient 2 is a 67-year-old male with an asymptomatic 4.0-cm AAA and L iliac chronic total occlusion (CTO) and disabling claudication. Both patients were poor operative candidates for open repair. Both patients underwent elective percutaneous EVAR along with left iliac artery revascularization. Initial angiography in both cases showed a blind ending of the left common iliac artery. Retrograde subintimal dissection through the occluded iliac segment was attempted but in both cases the wire was unable to traverse back into the true aortic lumen. Using either the Outback LTD or Pioneer reentry catheter, direct visualization of the true aortic lumen was obtained to re-enter the true lumen. The subintimal iliac tract was then predilated to facilitate routine EVAR in both cases. Both patients were discharged the following day and 1-year and 6-month follow-up imaging revealed aneurysm exclusion, no endoleak, and patent bilateral common iliac arteries with resolution of claudication symptoms and normal ankle-brachial indexes. The previously patent internal iliac artery was preserved. While not always technically possible, reentry device aided EVAR is safe, feasible, and durable in the mid-term and avoids the morbidity and mortality related to aortouniiliac/femoral-femoral bypass and open repair. This technique should be considered in patients with iliac artery CTO and concurrent AAA to allow total endovascular repair.

Midterm Outcomes of Stent Placement for Long-segment Iliac Artery Chronic Total Occlusions: A Retrospective Evaluation in a Single Institution

PurposeTo assess the clinical and patency results of stent placement for long-segment iliac artery chronic total occlusions (CTOs). Materials and MethodsA retrospective analysis of 217 patients (141 men and 76 women; mean age, 76.6 y; 256 limbs) with long-segment (>5cm) iliac artery CTOs treated with stent placement was conducted in a single institution from January 2005 to July 2011. Demographics, clinical presentation, classification, comorbidity, ankle-brachial index (ABI) before and after treatment, technical success, patency, and complications were recorded at follow-up. The approach was initial access from the left brachial artery or the contralateral femoral artery. ResultsAccording to the TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) classification, 27 patients were type B, 143 were type C, and 47 were type D. Clinical presentation was recorded according to the Rutherford-Becker classification: 35 patients presented with stage 3; 108, with stage 4; 53, with stage 5; and 21, with stage 6. Technical success was 96.5% (247 of 256). Periprocedural in-stent thrombosis occurred in nine patients and was treated successfully with catheter-directed thrombolysis. ABI increased from 0.36±0.16 (range, 0–0.57) before the procedure to 0.79±0.24 (range, 0.56–1.12) after the procedure. The mean duration of follow-up was 25.4 months (range, 1–72 months). The primary, primary assisted, and secondary patency of the iliac artery was 95.1%, 98.4%, and 99.2% at 1 year and 91.9%, 95.6%, and 97.5% at 2 years, respectively. Major complications were encountered in 17 (6.6%) patients, and minor complications occurred in 12 (4.7%) patients. ConclusionsThese data suggest that stent placement is an effective, safe, and feasible method for treating long-segment iliac artery CTOs.

9:20 AM Abstract No. 22 - Subintimal recanalization of difficult iliac and femoral artery chronic total occlusions using a reentry device: a single-center experience

Purpose To present our experience with the technical outcome of the endovascular recanalization of occluded iliac and femoral arteries using Outback LTD reentry catheter when conventional tools and techniques fail to reenter the true arterial lumen. Materials and Methods A retrospective review was performed on 33 consecutive patients (25 men; mean age +/- SD, 75 years +/- 12) who underwent endovascular treatment for iliac and femoral arterial occlusions during a period of 67 months, from December 2006 to July 2012, at a single tertiary-care medical center. The Outback LTD reentry catheter was used to regain access into the true arterial lumen over a 0.014-in wire from the subintimal space following unsuccessful attempts with conventional guidewires. Immediate and late adverse effects (mean length of follow-up 12 months) were assessed. Results Procedure outcome was improved by achieving true lumen reentry in 79% (n = 26) of patients with iliac and femoral occlusions. Causes of failure included inability to re-enter the true lumen (n=5), acute angle of aortic bifurcation (n=1), and difficulty tracking the device through the lesion (n=1). Encountered acute procedure-related complications included acute thrombosis of the CFA and SFA (n=1), iliac artery perforation (n=2), and distal embolization (n=1). These complications were corrected immediately with endovascular techniques (n=3) or open surgical embolectomy (n=1), without any procedure-related late adverse effects. Conclusion This study shows that use of reentry catheters significantly improves the outcome of endovascular treatments in patients who otherwise would have required surgical intervention with its associated higher morbidity, cost, and hospital stay with no long term adverse effects. The incidence of iliac complications is concerning, however the majority of complications could be managed with endovascular techniques. In conclusion, the Outback LTD reentry catheter is an effective endovascular tool, the use of which enhances the likelihood of successful subintimal recanalization of chronic occlusions in iliac and femoral arteries.

Successful recanalization of a left common iliac artery chronic total occlusion adjacent to an ectopic renal artery at the aortoiliac bifurcation

Ectopic kidneys are rare and usually present incidental findings during invasive or non-invasive angiography. Their parenchyma is not more susceptible to disease and symptoms occur mainly due to alteration of the anatomic relations. The main renal artery of the ectopic kidney derives invariably from the aorta; however, accessory renal arteries may originate from almost any arterial branch adjacent to the ectopic kidney. Knowledge of the common anatomic variations is important during complex peripheral interventions. We present the case of a 46-year-old male with symptoms of claudication secondary to left common iliac artery occlusion. He was diagnosed as occlusion of the left common iliac artery at the aortoiliac bifurcation in close proximity to the ectopic renal artery by peripheral angiography, and percutaneous intervention of the left common iliac artery was successful. Percutaneous intervention led to resolution of the patient's symptoms of claudication as well as preservation of the ectopic renal artery. In such cases, renal ectopy and aberrant arteries should be promptly recognized in order to avoid vascular or renal complications.

RR6. The Use of Reentry Devices Improves the Technical Success, Safety, and Patency of Recanalization of Chronic Total Occlusions of the Iliac Arteries

Our aim was to analyze the effect of reentry device use on iliac artery chronic total occlusion (CTO) recanalization outcomes. A retrospective review of patients with iliac artery CTO treated with subintimal angioplasty (SIA) from 2006 to 2011 was completed. We then compared the outcomes of two groups: those procedures completed with versus those procedures completed without a reentry device using SPSS software (IBM, Armonk, New York). Of the 121 iliac artery CTOs that underwent SIA, 32 cases used a reentry device while 89 did not. For the entire cohort, the mean age was 65, male 45%, hypertension 76%, hyperlipidemia 71%, diabetes 36%, and CAD 56%. Indications for the procedure included claudication (60%) and critical limb ischemia (40%). The clinical profile and indications for intervention were not statistically different for the 2 groups. Combining TASC C&D lesions, the reentry device group had a trend toward a higher percentage of more advanced lesions compared to the non reentry device group (82% versus 66% P = .07). Yet despite the more advanced lesions, the technical success rate was higher in the reentry device group (100% versus 77% P = .002). Combined major complication rate, retrograde aortic dissection, and 30-day mortality rate of the reentry group was also reduced (0% versus 10% P = .04). Lastly, the 1, 2 and 3 years primary and secondary patency rates, especially with long term follow up, appear to be improved with the use of reentry devices; primary patency at 1, 2, and 3 years for the reentry device group versus the non reentry device group (100%, 100%, 100% versus 84%, 72%, 64% P = .02), and secondary patency at 1, 2, and 3 years for the reentry device group versus the non reentry device group (100%, 100%, 100% versus 93%, 91%, 77% P = .125). The routine use of reentry devices further improves the technical success, safety, and primary patency of SIA recanalization of iliac artery CTO.

Single-Incision External Iliac Artery Endarterectomy and Patch Angioplasty

An isolated external iliac artery chronic total occlusion is currently treated either with subintimal percutaneous transluminal angioplasty and stent or with a bypass. This article describes a new application of an old technique, endarterectomy and patch angioplasty, performed on the external iliac artery through a single flank incision. This novel approach can provide lasting patency with a low risk of complications. We present four cases and a review of the literature on the other available treatment options. This minimally invasive technique may provide a viable alternative that can be used alone or in combination with other open or endovascular techniques and can be applied in cases of groin sepsis.

Subintimal angioplasty of chronic total occlusion in iliac arteries: A safe and durable option

Traditionally, aortobifemoral bypass has been the intervention of choice for iliac artery chronic total occlusions (CTOs). However, it is associated with significant morbidity and mortality, limiting its use in high-risk patients. To reduce procedural risk, subintimal angioplasty (SIA) for femoropopliteal CTO has been utilized by many, but few have extended this endovascular technique to treating iliac artery CTOs. We present our experience with 101 successful SIAs for iliac artery CTOs. A retrospective review of consecutive patients with iliac artery CTOs treated with subintimal angioplasty from June 2000 to January 2009 was completed. Demographic and risk factor data were obtained, along with procedural data. Primary and secondary patency, survival, freedom from claudication, and limb salvage rates were determined by Kaplan-Meier survival analysis. Univariate and multivariate analyses were completed to identify factors adversely affecting primary patency. One hundred twenty patients underwent an attempted SIA of an iliac artery CTO, and 101 iliac artery CTOs were successfully treated, giving a technical success rate of 84%. Technical failure was due to the inability to re-enter the lumen in all cases. Indications for intervention were lifestyle-altering claudication in 64 patients (63%) and critical limb ischemia (CLI), in 37 (37%). Eighty-five patients underwent percutaneous SIA, while 11 patients underwent a combined SIA with surgical outflow procedure. Lesions were classified as TransAtlantic InterSociety Consensus (TASC) B, 39 (39%); TASC C, 27 (27%); and TASC D, 35 (35%). In 82 (81%) lesions, stents were deployed with an average of 1.2 (range, 0-3) stents utilized. A re-entry device was used in 14 (14%) lesions. Major complication rate was 3.0%, with a 30-day mortality rate of 1.0%. Primary and secondary patency rates at 1, 2, and 3 years were 86% and 94%, 76% and 92%, and 68% and 80%, respectively. Survival rate was 67% at 5 years, reflecting the poor health of this cohort. Limb salvage for CLI patients at 1 and 5 years was 97% and 95%, respectively. Freedom from claudication at 1 and 3 years was 89% and 73%. Univariate analysis identified hyperlipidemia, coronary artery disease, and prior surgical bypass in treated limb as factors for loss of primary patency; however, on multivariate analysis, no factors remained statistically significant. This study demonstrates that SIA of iliac CTOs is feasible and can be performed safely and effectively, even in high-risk patients. Excellent patency and limb salvage rates can be achieved. In our experience, the safety and durability of SIA makes it an attractive first-line therapy for iliac artery occlusive disease.

Primary stent placement for iliac artery chronic total occlusions

The purpose of this study was to evaluate the technical and mid-term results of primary stent placement for chronic total occlusions (CTO) of the iliac artery, in comparison to stent placement for iliac artery stenosis. A retrospective study was carried out on 114 consecutive limbs with 24 CTOs and 90 stenoses of the iliac artery that underwent primary stent placement. Primary, assisted primary patency, and limb salvage rates were determined in accordance with the Society for Vascular Surgery guidelines. Angiographic and intravascular ultrasonographic success was achieved in all 114 limbs (100%). Three major complications, including 1 distal embolism and 2 arterial ruptures, occurred in the CTO group. The 2-year primary patency rate in the CTO group was as high as that observed in the stenosis group (91% vs 89%). There were also no significant differences in the assisted primary patency, limb salvage, and survival rates between the two groups. Our results indicate that primary stent placement is a safe and effective treatment for iliac CTOs. However, major complications, including distal embolization and iliac artery rupture, remain a significant problem, and caution should therefore be exercised when performing this technique for iliac CTOs.