Iliac Artery Stent Research Articles

Case Report: Endovascular Repair of An Internal Iliac Arteriovenous Fistula Secondary to Penetrating Trauma 20 Years Prior to Current Presentation

Acquired arteriovenous fistula (AVF) subsequent to penetrating trauma is a known vascular entity with well-documented pathophysiology. Acquired AVF located in the iliac arteries are rare event. We present a patient with a symptomatic high-output traumatic AVF between the left internal iliac artery and external iliac vein (Fig 1). The AVF occurred secondary to an abdominal gunshot wound sustained by the patient 20 years before presentation. The patient presented with classic symptomatology, including leg swelling and congestive heart failure. The patient underwent endovascular repair with covered stenting of the left internal iliac artery, which excluded the AVF and maintained arterial patency (Fig 2). Exclusion of the AVF was confirmed at the time of surgery and at 1 month and 6 months. This case report describes the successful endovascular repair of a traumatic internal iliac artery AVF and reviews the recent literature regarding proximal AVF. Endovascular repair of acquired proximal (aortic/iliac) AVF has become the treatment of choice given the high rates of success and minimal morbidity. Open surgery for proximal AVF is reserved for cases in which endovascular intervention is not feasible.Fig 2Computed tomography reconstruction of a traumatic arteriovenous fistula (AVF) after endovascular repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Delay in Transfer Adversely Impacts Mortality and Cost of Care in Patients With Ruptured AAA

to 2014 at St. Joseph Mercy, Ann Arbor. Patient demographics, presenting complaints, operative details, and complications were analyzed. Postoperative patency was assessed by comparison of ankle-brachial index values and qualitative patient improvement. Data was analyzed by way of paired Student t-test and c values with significance defined as a P value of <.05. Results: A total of 39 limbs were intervened upon in 32 patients. In 19 limbs (49% of patient cohort), the procedure was performed for critical limb ischemia (n 1⁄4 8, rest pain; n 1⁄4 11, tissue loss/gangrene). Twenty-five limbs (64%) received an external iliac artery stent with procedure. The median external iliac artery stent diameter was 10 mm (range, 8-16 mm). The preintervention ankle-brachial index was 0.45 6 0.24 (n 1⁄4 32 limbs) and significantly improved to 0.74 6 0.27 (n 1⁄4 28 limbs; P < .001). In addition, preintervention toe pressure of 34 6 28 (n 1⁄4 27 limbs) improved to 58 6 26 (n 1⁄4 22 limbs; P < .001). Average follow-up postintervention was 13 6 14.6 months. One limb (3%) required an additional outflow bypass. At last follow-up, no patient needed subsequent primary assisted patency or additional infrainguinal revascularization. Conclusions: Hybrid-based external iliac and femoral endarterectomy provides a robust, less invasive approach to severe external iliac stenosis or occlusion compared to aortofemoral bypass. Dramatic inflow improvement was observed in our series, and the need for additional outflow revascularization was virtually eliminated. The procedure was deemed technically feasible and safe, with a low number of adverse sequela and excellent primary patency achieved more than 1 year postintervention.

The effect of demographic factors and lesion severity on iliac stent patency

The aim of our study was to perform a large multivariate analysis to identify demographic, anatomic, or procedural factors that affect iliac artery stent primary patency (PP). Patients receiving iliac stents from 2007 to 2013 were retrospectively reviewed. Univariate analysis assessed cohort characteristics and their effect on PP. Variables considered significant (P < .05) were brought forward in the multivariate analysis. A total of 213 patients underwent primary iliac artery stenting, and 307 limbs were analyzed. The average age was 66 years (range, 38-93 years), 54% were male, and 55% were Caucasian. Indications for procedure were claudication in 68%, rest pain in 20%, and tissue loss in 12%. All TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II classifications were included: 51% TASC II A, 25% TASC II B, 13% TASC II C, and 11% TASC II D. The treated anatomic locations were 27% isolated external iliac artery (EIA), 56% isolated common iliac artery, and 17% combined common iliac artery and EIA. Multivariate analysis found three factors were correlated with decreased PP: non-Caucasian race (hazard ratio [HR], 1.84; 95% confidence interval [CI], 1.08-3.13; P = .025), younger age (HR, 1.04; 95% CI, 1.01-1.08; P = .006), and presence of EIA occlusion (HR, 2.02; 95% CI, 1.05-3.89; P = .036). Overall, Kaplan-Meier analysis at 1 and 3 years revealed a PP of 86% and 53%, assisted PP of 98% and 89%, and secondary patency of 99% of 98%. Kaplan-Meier analysis showed PP at 1 year for was 91% Caucasian patients vs 77% for non-Caucasian (P = .001). PP was 75% in patients aged <60 years, 86% in patients aged 60-70 years, and 96% in patients aged >70 years, with a significant difference between all groups (P < .001). PP was significantly different for those with and without EIA occlusion (P = .002), with 1-year PP of 71% and 88%, respectively. In our experience with a large number of iliac interventions, younger age, non-Caucasian race, and EIA occlusion were strong predictors for loss of PP.

Patency of the Internal Iliac Artery After Placement of Common and External Iliac Artery Stents

Patency of the Internal Iliac Artery After Placement of Common and External Iliac Artery Stents

Iliac anatomy and the incidence of adjunctive maneuvers during endovascular abdominal aortic aneurysm repair.

PurposeChallenging iliac anatomy remains an important issue during endovascular aneurysm repair (EVAR), and it is known that the length of the common iliac artery (CIA) is shorter in Asians than in Western groups. We analyzed both the iliac anatomy and the incidence of adjunctive maneuvers to overcome iliac artery-related difficulties during EVAR.MethodsSeventy-four EVARs were performed for abdominal aortic aneurysm between January 2010 and March 2013. Patient demographic data, iliac anatomical characteristics (presence of iliac artery aneurysm, iliac artery diameter and length, and iliac tortuosity), and adjunctive iliac artery maneuvers were reviewed retrospectively.ResultsMean CIA length was 52.8 mm (range, 6.6-98.0 mm) on the right and 56.3 mm (range, 0-94.8 mm) on the left. CIA length was ≥20 mm, except in one patient with bilateral short CIAs. Forty patients (54%) had a CIA aneurysm, and 18 had aneurysms on both sides. Iliac adjunctive procedures were performed in 38 patients (51%) as follows: 23 internal iliac artery (IIA) embolizations or ligations, seven IIA revascularizations, 16 external iliac artery (EIA) balloon angioplasties or stenting, one EIA patch angioplasty, one EIA interposition, two femoral endarterectomies with patch angioplasty, and nine femoro-femoral bypasses after EVAR with an aorto-uni-iliac device. Technical success for the adjunctive iliac procedures was achieved in all patients.ConclusionShort CIA length was uncommon. Although many patients had access-related difficulties, most were overcome by an endovascular or hybrid technique. Liberal use of iliac adjunctive procedures can facilitate EVAR.

Bilateral Common Iliac Artery Stenosis: A Novel Technique for Deployment of Kissing Iliac Artery Stents

Treatment for bilateral proximal iliac disease can be technically challenging, typically requiring simultaneous stent deployment to minimise complications. Up to three operators are required for exact simultaneous deployment of the balloons, contributing to increased operator time and costs. This technical note demonstrates a novel approach to simultaneous stent deployment which uses readily available, inexpensive equipment and minimises the technical difficulty of simultaneous balloon deployment.

TCT-447 Usefulness of Polyzene-F nanocoated stent to facilitate reendothelialization and reduce thrombus formation. In vivo results of stented rabbit iliac arteries

The CeloNova COBRA PzF™ Coronary Stent is a new stent design, balloon expandable cobalt chromium alloy coronary stent that is pre-mounted on a custom rapid exchange balloon delivery catheter. The alloy stent is surface treated with a nano-layer Polyzene®-F (PzF). Polyzene-F is an inorganic

Use of iliac branch devices for endovascular repair of aneurysmal distal seal zones after EVAR.

To assess the feasibility and midterm outcomes of iliac branch devices (IBD) for the treatment of aneurysmal distal seal zones after endovascular aneurysm repair (EVAR). Between January 2005 and January 2014, 188 patients with aortic aneurysms involving the iliac bifurcation underwent IBD implantation; of these, 18 consecutive patients (17 men; mean age 70±10 years) were treated for aneurysmal degeneration of 22 distal seal zones (mean 36±6-mm diameter) after EVAR. The main outcome measure was technical success. Further outcomes were primary and assisted primary patency of the internal iliac branch, types Ib/III endoleaks, reintervention, and all-cause mortality. The technical success rate was 100%. The primary patency rate was 100% over a median follow-up of 15 months (interquartile range 4-25). None of the patients developed type Ib or III endoleak. During surveillance, two device-related reinterventions were performed (thrombectomy of an occluded external iliac artery and angioplasty with stenting of a stenotic common iliac artery). One patient died due to metastatic prostate cancer. Iliac side branch endografting showed excellent feasibility and encouraging midterm outcomes for the challenging endovascular repair of aneurysmal distal seal zones post EVAR.

Everolimus-eluting stents improve vascular response in a diabetic animal model.

Preclinical evaluation of the vascular response of drug-eluting stents is limited especially in the setting of diabetes mellitus preventing the evaluation of changes in drug-eluting stent design and eluted drugs after clinical use. Cultured human aortic endothelial cells were used to assess the differences between sirolimus and its analog, everolimus, in the setting of hyperglycemia on various cellular functions necessary for endothelial recovery. A diabetic rabbit model of iliac artery stenting was used to compare histological and morphometric characteristics of the vascular response to everolimus-eluting, sirolimus-eluting, and bare metal stent placement. Under hyperglycemic conditions, sirolimus impaired human aortic endothelial cell barrier function, migration, and proliferation to a greater degree compared with everolimus. In our in vivo model of diabetes mellitus, endothelialization at 28 days was significantly lower and endothelial integrity was impaired in sirolimus-eluting stent compared with both everolimus-eluting and bare metal stents. Neointimal area, uncovered struts, and fibrin deposition were significantly higher in sirolimus-eluting compared with everolimus-eluting and bare metal stents. Use of everolimus-eluting stent results in improved vascular response in our preclinical models of diabetes mellitus.

Stenting of Iliac Artery through Brachial Approach

In some cases the iliac artery occlusive disease cannot be approached through standard access. The preferred access sites are the ipsilateral retrograde femoral and the contralateral antegrade cross-over, although occasionally these approaches do not allow an effective engagement of the lesion, especially when there is a total occlusion or complex aortoiliac lesion. We are reporting a case of iliac artery stenting through brachial approach.This technique is safe and effective. It provides enough support for stiff balloon or stent catheter to be advanced through this long sheath. DOI: http://dx.doi.org/10.3329/cardio.v6i2.18360 Cardiovasc. j. 2014; 6(2): 164-166

Unknown pages in the history of vascular stent grafting

Unknown pages in the history of vascular stent grafting

Quiz Page March 2014: A Patient With Malignant Hypertension, Thrombotic Microangiopathy, and Nephrotic-Range Proteinuria

A 63-year-old white man with peripheral vascular disease who had undergone bilateral iliac artery stent placement 3 weeks earlier was admitted to the hospital with weight loss, hypertensive urgency, and thrombocytopenia. His medications included aspirin and clopidogrel. Laboratory results showed non-nephrotic proteinuria and microscopic hematuria; specific values included hemoglobin, 11.4g/dL (which later decreased to 6.8g/dL), platelet count, 62×103/μL, serum haptoglobin, <10mg/dL, and serum creatinine, 2.0mg/dL, corresponding to estimated glomerular filtration rate (eGFR) of 33mL/min/1.73m2 using the 4-variable MDRD (Modification of Diet in Renal Disease) Study equation.

The influence of gender on patency rates after iliac artery stenting

The purpose of this study was to investigate the influence of gender on the long-term outcome after iliac artery stenting and to assess gender-specific differences of the influence of risk factors on treatment success and patency rates. Between January 2000 and December 2006, 404 percutaneous transluminal angioplasties with primary stent deployment for symptomatic iliac artery occlusive disease were performed at our center. These included 128 interventions in women and 276 interventions in men. Whereas average age was significantly higher (65.9 ± 12.9 years; P = .007) and arterial hypertension more frequent (60.9% vs 49.3%; P = .032) in women, hyperuricemia (7.0% vs 14.1%; P = .047) and a positive smoking status (61.7% vs 74.3%; P = .014) were more frequently observed in men. Fontaine stage was more advanced (stages III and IV) in women than in men (P = .028; P < .001). Technical success was 97.7% in women and 99.3% in men. Overall complication rate was higher in women compared with men (P = .002), mostly caused by access site hematomas (4.7% vs 0.4%) and pseudoaneurysms (8.6% vs 2.5%). Patients were followed up for 45.0 ± 33.3 months. Restenosis developed in 16.8% of cases in women and in 14.6% of cases in men and was treated in 73.7% by an endovascular approach. Primary patency rates at 1, 3, 5, and 7 years were 90.3%, 77.2%, 60.2%, and 46.4% in women and 89.9%, 71.5%, 63.6%, and 59.7% in men, respectively (P = .524; log-rank, .406). Secondary patency rates were 97.2%, 91%, 81.5%, and 70.3% in women and 97.1%, 89.1%, 82.6%, and 78% in men, respectively (P = .959; log-rank, .003). Multivariate analysis identified lower age as the only independent risk factor for recurrent disease in both groups. Age-defined subgroup analysis showed a restenosis/reocclusion rate of 23.9% in men and 22.1% in women older than 63.5 years (P = .861) but 32.1% in men and 49.1% in women younger than that (P = .034). Our data suggest that although women are older and present with a more advanced stage of peripheral arterial occlusive disease, endovascular therapy is equally effective irrespective of gender. Surprisingly, the subgroup of young female patients had a specifically poor outcome.

Factors affecting primary patency of stenting for TransAtlantic Inter-Society (TASC II) type B, C, and D iliac occlusive disease

Background and objectiveThe purpose of our study was to evaluate 1- and 2-year results and the influence of risk factors on the outcome in the patients undergoing iliac artery stenting for TASC II type B, C, and D iliac lesions. Materials and methodsIn this prospective nonrandomized study conducted between April 15, 2011, and April 15, 2013, 316 patients underwent angiography with a diagnosis of aortoiliac atherosclerotic disease. Of these, 62 iliac endovascular procedures (87 stents) were performed in 54 patients. ResultsThe indications for revascularization were disabling claudication (Rutherford 2, 5.9%; Rutherford 3, 35.2%), rest pain (Rutherford 4, 22.2%), and gangrene (Rutherford 5, 16.7%). The overall complication rate was 9.2%. The cumulative primary stent patency at 1 and 2 years was 83.0%±5.2% and 79.9%±5.8%, respectively. Early stent thrombosis in ≤30 days was detected in two patients (3.7%). The primary patency rates for the stents ≤61mm at 12 and 24 months were 90.6%±4.5% and 86.6%±5.8%, respectively; those for the stents >61mm were 67.7%±10.9% and 60.2%±12.0%, respectively (P=0.016). The multivariate Cox regression analysis enabled the localization of a stent in both the CIA and the EIA (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.1–9.5; P=0.021) and poor runoff (HR, 3.2; 95%, CI 1.0–10.0; P=0.047) as independent predictors of decreased stent primary patency. ConclusionsThe localization of a stent in both iliac (CIA and EIA) arteries and poor runoff significantly reduce the primary stent patency. Patients with stents >61mm have a higher risk of stent thrombosis or in-stent restenosis development.

Assessment of Biocompatibility of the Multilayer Flow Modulator with Differing Thread Designs

Background: The Multilayer Flow Modulator (MFM) (Cardiatis, Isnes, Belgium) is a self-expandable mesh of cobalt alloy wires used for the treatment of aortic aneurysms. The impact of design thread count and duration of implantation on the biocompatibility of the MFM in porcine animal models was assessed in this study. Methods: Eight mini-piglets received 26 MFM devices (12 with 56 threads, 14 with 80-96 threads) in the iliac, carotid, and renal arteries. Animals were sacrificed and specimens explanted at 1, 3, and 6 months, at which time histological and ultrastructural analyses were carried out. Results: The MFM was successfully deployed in 25 of the 26 implanted cases. The 56 thread devices were well tolerated locally and yielded fewer signs of inflammation and neo intimal hyperplasia. Percentage stenosis was 16.9% ± 5.1% for the 56 thread devices versus 33.4% ± 10.2% for the 80-96 thread devices (p=0.001) at 3 months, and 21.7% ± 9.9% for the 56 thread devices versus 33.6% ± 12.4% for the 80-96 thread devices (p=0.004) at 6 months. The 5 devices selected for SEM examination were well deployed, integrated into the vessel wall and endothelialized, and had patent side branches. Conclusions: No significant stenosis formation or inflammatory response was recorded in any of the implanted animals. The 80-96 thread devices elicited a greater intra-arterial response than the 56 thread devices, although the values for both groups remained within the normal range for stented carotid, renal, or iliac arteries. Further preclinical and clinical studies will extend assessment of the long-term safety and effectiveness of the MFM

Fine-motor skills testing and prediction of endovascular performance

Performing endovascular procedures requires good control of fine-motor digital movements and hand-eye coordination. Objective assessment of such skills is difficult. Trainees acquire control of catheter/wire movements at various paces. However, little is known to what extent talent plays for novice candidates at entry to practice. To study the association between performance in a novel aptitude test of fine-motor skills and performance in simulated procedures. The test was based on manual course-tracking using a proprietary hand-operated roller-bar device coupled to a personal computer with monitor view rotation. A total of 40 test repetitions were conducted separately with each hand. Test scores were correlated with simulator performance. Group A (n = 14), clinicians with various levels of endovascular experience, performed a simulated procedure of contralateral iliac artery stenting. Group B (n = 19), medical students, performed 10 repetitions of crossing a challenging aortic bifurcation in a simulator. The test score differed markedly between the individuals in both groups, in particular with the non-dominant hand. Group A: the test score with the non-dominant hand correlated significantly with simulator performance assessed with the global rating scale SAVE (R = -0.69, P = 0.007). There was no association observed from performances with the dominant hand. Group B: there was no significant association between the test score and endovascular skills acquisition neither with the dominant nor with the non-dominant hand. Clinicians with increasing levels of endovascular technical experience had developed good fine-motor control of the non-dominant hand, in particular, that was associated with good procedural performance in the simulator. The aptitude test did not predict endovascular skills acquisition among medical students, thus, cannot be suggested for selection of novice candidates. Procedural experience and practice probably supplant the influence of innate abilities (talent) over time.

Initial Results of Transradial Iliac Artery Stenting

Iliac artery stenting is commonly performed via the ipsilateral or contralateral femoral artery. However, transradial intervention is less invasive than the transfemoral approach. We evaluated initial results of transradial iliac artery stenting. We implanted stents in 32 iliac arteries of 30 patients via the radial artery. Transradial intervention was attempted at the discretion of the operator. Clinical data were analyzed retrospectively. Patients were excluded using a scheduled bidirectional approach. Twenty-one patients were male. In all, 8, 20, 16, and 9 patients had diabetes mellitus, hypertension, dyslipidemia, and smoking habit, respectively. In all, 30 lesions were stenosed and only 2 were occluded. A total of 39 stents were inserted, of which 36 were E-Luminexx stents and the other 3 were SMART control stents. All lesions were successfully treated with a good final angiographic result via a 6F radial access system. Ankle brachial index significantly improved from 0.68 ± 0.13 to 0.92 ± 0.15 (P < .01). Hospital stay was 2.09 ± 1.12 days. None of the patients had any procedural or access site-related complications (hematoma, major bleeding, blood transfusion, stroke, cholesterol embolism, aortic dissection, or arterial perforation). Transradial iliac artery stenting is a feasible and safe alternative in carefully selected patients.

Short- and Midterm Results of Iliac Artery Stenting for Flush Occlusion with the Assistance of an Occlusive Contralateral Iliac Artery Balloon

Endovascular treatment of flush iliac artery occlusion remains a challenge and is most often performed using open surgery. We report the outcomes of 10 cases that were successfully recanalized endovascularly with the assistance of a contralateral occlusive balloon. A retrospective review of patients undergoing iliac artery stenting was performed at a single institution. Technical success, short- and midterm patency, and 30-day complications are reported. Ten patients were identified. Technical success was 100% when a brachial approach was used. Retrograde recanalization was attempted in 3 cases. Reentry into the aorta could not be achieved in 1 case. The aorta was entered above the inferior mesenteric artery (IMA) in the other 2 cases, and the decision was made to attempt a brachial approach to avoid stenting above the IMA. There were no dissections or perforations. Two patients developed brachial access complications, but only 1 required operative repair for a pseudoaneurysm. Nine patients (90%) remained patent at a mean follow-up of 14.6 months (range 9-24 months). One patient presented 9 months later with iliac artery stent and lower extremity bypass thromboses, which resulted in an amputation. There were no deaths in this series. Iliac stenting for flush iliac artery occlusion can be achieved with this technique with encouraging short- and midterm results and minimal morbidity.

Reporting standards for adverse events after medical device use in the peripheral vascular system

New York, NY;Phoenix, Ariz; Houston, Tex; London, Ontario, Canada; Delhi, India; Silver Spring, Md; and Lewiston, MeAdverse event reporting after medical device implanta-tion is essential to understanding the safety and perfor-mance of a device. Standardization of reporting attainsgreat importance when comparing different devices andfor the ongoing surveillance of a marketed device.Although some work has been done to standardize adverseevent reporting for medical devices, a single reference withrecommendations that span investigational and postmarketuse does not exist.Standardization of nomenclature for reporting vascularconditions is one of the objectives of the Society forVascular Surgery (SVS) in its Bylaws.

Comparison of haemodialysis and non-haemodialysis patients in 6-year clinical outcomes after iliac artery stenting

Background: Endovascular therapy (EVT) has become widely performed for peripheral artery disease (PAD) even in haemodialysis (HD) patients. In general population, favorable outcomes have been obtained after EVT for lesions of iliac artery. However, clinical outcomes after EVT for iliac artery lesions have not been fully evaluated in HD patients. We investigated the impact of HD on long-term outcome after iliac artery stenting. Methods: A total of 2096 patients undergoing successfully iliac artery stenting were enrolled from multi-center registry in Japan. Six-year clinical outcomes were compared between HD group (n=377) and non-HD (NHD) group (n=1719). Endpoint was defined as major adverse cardiovascular events (MACE) including death, myocardial infarction (MI) and stroke. Primary patency and major amputation were also analyzed. To reduce the differences of clinical and procedural characteristics between two groups, propensity score matching with all baseline variables was performed. Results: Prevalence of diabetes, coronary artery disease and critical limb ischemia (≥Rutherford grade IV) were higher in HD group than in NHD group. By Kaplan-Meier analysis, 6-year event-free survival rate from MACE was significantly lower in HD group than in NHD group (46.9% vs. 76.1%, p<0.0001). In addition, both primary patency rate and limb salvage rate were lower in HD group than in NHD group (64.2% vs. 75.1%, p=0.0004, and 96.7% vs. 99.3%, p=0.013, respectively). After propensity score analysis, survival rate from MACE was still lower in HD group than in NHD group [58.7% vs. 80.2%, hazard ratio (HR) 1.90, 95% confidence interval (CI) 1.42-2.55, p<0.0001 for MACE and 61.6% vs. 85.7%, HR 1.91, 95% CI 1.43-2.56, p<0.0001 for mortality, respectively], and patency rate was also lower in HD group than in NHD group (65.0% vs. 77.9%, HR 1.34, 95% CI 1.00-1.80, p=0.047). Conclusion: Even after adjusting for clinical and procedural differences, HD was identified as an independent predictor of poor outcome after iliac artery stenting. Detection at the early stage of PAD is especially needed in this population.