Iliac Artery Stent Research Articles

Long-Term Results of Treatment of Aortoiliac Occlusive Disease With the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique: A UK Multicenter Study.

This updated UK multicenter study aims to report long-term results following use of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique for treating aortoiliac occlusive disease (AIOD) in patients with chronic limb-threatening ischemia (CLTI) or intermittent claudication (IC). A retrospective analysis was conducted including 85 patients who underwent CERAB between November 1, 2012, and March 31, 2020, till March 2024. Anatomical data were assessed using pre-operative imaging. Outcome measures included freedom from target lesion reintervention (fTLR), freedom from major limb amputation (fMLA), and overall survival. The median age was 65 years, with 62.4% males. Over a median follow-up of 58.2 months (IQR 55.7-67.1 months), 2 patients were lost to follow-up. There were 16 deaths (18.8%) and 2 major amputations (2.4%) in the entire study period. Target lesion reintervention was required in 14 patients (16.5%) at the last follow-up. The Kaplan-Meier fTLR at 1, 3, and 5 years was 89.2%, 83.0%, and 83.0%, respectively. fMLA at 1, 3, and 5 years was 98% at all intervals, and survival rates at 1, 3, and 5 years were 94.1%, 89.4%, and 80.1%, respectively. Subintimal iliac access was associated with worse fTLR (HR 4.33 (95% CI 1.30-14.37, p=0.017)), which remained significant when adjusted to patient and anatomical characteristics (HR 5.88 (95% CI 1.02-33.95, p=0.047)). There was no significant association between fTLR and the need for common femoral endarterectomy (HR 3.57 (95% CI 0.42-30.5, p=0.244)] or external iliac artery stenting (HR 0.47 (95% CI 0.07-3.05, p=0.427)) during the index procedure. The long-term outcomes of CERAB for treating AIOD demonstrate its viability as a durable revascularization option, with acceptable morbidity, mortality, and patency rates. Factors reflecting more complex lesions are associated with poorer outcomes. Findings support the need for randomized controlled trials on CERAB and a focus on the pre- and intra-operative decision-making based on the complexity of TASC C and D lesions. The findings of this study reinforce the long-term durability of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique for treating aortoiliac occlusive disease (AIOD), demonstrating favourable reintervention and limb salvage rates. These results support CERAB as a viable alternative to open surgery, particularly in patients with complex anatomies or significant comorbidities. This data enables clinicians to make more informed decisions regarding patient selection and procedural strategies, such as minimising the use of subintimal iliac access to improve long-term outcomes. The study underscores the need for further randomised trials to establish CERAB's role in evidence-based clinical guidelines for AIOD management.

Kidney graft directly implanted on endovascular stent in external iliac artery: A preliminary experience.

With an increasingly aging population, both end-stage renal disease and peripheral artery disease become more prevalent. Peripheral artery disease is increasingly treated with endovascular procedures. Endovascular stenting of the external iliac artery is often considered a contraindication for kidney transplantation, as clamping of the artery could result in possible injury to the stent. In this study, we describe our first 2 cases of kidney transplantation with a graft placed on a self-expandable metal stent and a covered stent as part of an endovascular repair of the aortic bifurcation, using endovascular balloon occlusion to occlude the proximal side of the external iliac artery. Six months after transplantation, both recipients have good kidney function without any signs of ischemia of the ipsilateral limb. This study shows that it is feasible to place a kidney graft on an endovascular stent.

Endograft-specific hemodynamics after endovascular aneurysm repair: a CFD analysis

Intraluminal prosthetic graft thrombus (IPT) has been described in case of endovascular aortic pathology repair. This study aimed to assess hemodynamic indicators associated with various anatomical morphologies following endovascular aortic repair (EVAR), aiming to offer further references for the choice of clinical therapy. Six model models (normal, iliac compression, aortic compression, aortoiliac compression, iliac distortion, and long-leg stent) were established based on common anatomical morphologies following EVAR. Hemodynamic indicators, such as flow velocity, time-average wall shear stress (TAWSS), oscillatory shear stress index (OSI), and relative residence time (RRT), were captured using computational fluid dynamics (CFD), and the differences between the six models were examined. The peak blood flow velocity at the compressed side iliac artery and the uncompressed side iliac artery corresponding to the aortoiliac artery compression model and the aortic compression model decreased by 30.63% to 48.62%, compared with that in the normal model. Compared with that in the normal model, the peak blood flow velocity at the aorta and the distorted side iliac artery in the iliac distortion model decreased by 7.89% and 41.13%, respectively. The length of the iliac artery stent has little effect on the blood flow velocity. The TAWSS at Iliac grafts showed varying degrees of decline in the other three compression models, particularly in the aortic compression model compared to the normal model. The TAWSS increases at the corner of the artery showing distortion but exhibited a significant decrease toward the distal end of the corner. The areas with higher OSI, and longer RRT were concentrated in the aortoiliac compression model and the iliac distortion model. We found that endograft compression and distortion may be risk factors for IPT. Moreover, the influence of longer stents on the hemodynamics inside stent-grafts is negligible. However, future real-world studies should be conducted to test and verify this speculation.

Acute management of a ruptured mycotic iliac artery pseudoaneurysm in a young transplant patient.

Ruptured mycotic pseudoaneurysms are rare, yet devastating complications that can prove challenging to manage. In immunocompromised populations, highly virulent organisms such as Gemella morbillorum can be especially difficult to combat. Here, we outline our approach to temporizing maneuvers in an emergent setting and definitive revascularization in a 27-year-old with a ruptured mycotic iliac artery pseudoaneurysm from necrosis of her kidney and pancreas allografts. The initial staged repair involved covered stenting of the right iliac artery for hemorrhagic control of a ruptured pancreatic allograft arterial anastomosis, explant of ipsilaterally placed renal and pancreas allografts from the right pelvis, and iliac artery reconstruction using left femoral vein. Subsequent abscess formation leading to anastomotic blowout required repeat covered stenting followed by a femoral-femoral arterial bypass with right femoral vein. The patient was discharged home with no further vascular events and preserved lower extremity perfusion. They returned to the clinic 1month following discharge in stable condition with no wound healing or ischemic complications. The choice of femoral vein as conduit for in-line arterial repair can provide both better long-term patency and resistance to infection than prosthetic bypass material.

A prospective study of the method of intraoperative luminescent spectroscopy in the application of isolated profundoplasty in hybrid surgery of critical ischemia of the lower limb

Introduction. Currently, it is relevant to develop new diagnostic criteria for assessing the condition of the deep femoral artery (DFA), in order to determine the possibilities of its use in various hybrid reconstructions for critical lower limb ischemia.Aim: To determine the indications for isolated profundoplasty as the final stage of proximal hybrid reconstruction using the method of intraoperative luminescence spectroscopy.Material and Methods. The prospective open-label non-randomized pilot study included 64 people operated at City Clinical Hospital No. 29 with a clinical diagnosis of “Obliterating atherosclerosis of the arteries of the lower extremities. Stenosis of the external iliac artery. Steno-occlusive lesion of the common femoral/superficial femoral artery. Stenosis of the deep femoral artery of the thigh. Chronic arterial ischemia of the III st.”, in the volume of proximal hybrid reconstruction, including isolated profundoplasty. The first group (n = 28) consisted of patients who had stenosis or occlusion of the mouth of the deep femoral artery, the second group (n = 20) – had diffuse lesion of the deep femoral artery, the third group (n = 16) – had a distal type of lesion of this artery. The first stage of the hybrid operation was stenting of the external iliac artery. The choice of further intraoperative tactics occurred as a result of an assessment of the anatomy and severity of the lesion of the deep femoral artery, by measuring the ankle-shoulder and hip-popliteal indices. All patients underwent intravascular luminescent spectroscopy intraoperatively using our technique to determine the luminescent compensation coefficient (CI). The follow-up period was 3 months. The end point of the study was thrombosis of the reconstruction zone. The SPSS 17.0 software was used for statistical data processing when comparing study groups.Results. When comparing the obtained CI, a direct strong correlation was noted with a preoperatively determined hip-popliteal index (r = 0.76; at p < 0.005). When assessing the interval of the hip-popliteal index from 0.3 to 0.4; 4 patients with thrombotic complications in the early postoperative period and 3 patients with no thrombotic complications were evaluated. When correlating CI in these categories of respondents, the statistically significant differences in indicators were established: CI (without complications) = 0.46 (0.43; 0.50); CI (complicated) = 0.59 (0.58; 0.60); with p < 0.05. When studying preoperative deep femoropopliteal index in representatives of study groups 1 and 2 who had GPI in the range from 0.4 to 0.5, but differed in the outcomes of the late postoperative period, the statistical significance of differences in indicators was noted: Cl (without complications) = 0.44 (0.43; 0.46); Cl (complicated) = 0.61 (0.60; 0.62); at p < 0.05.Conclusion. Intravascular luminescence spectroscopy is an important method of clarifying the intraoperative feasibility of performing isolated profundoplasty in addition to preoperative assessment of the degree of the hip-popliteal index.

Abstract 4138449: High Output Heart Failure from an Aortocaval Fistula

Introduction: High output heart failure (HOHF) due to a post-traumatic aortocaval fistula is a rare entity. This case seeks to explore the presentation as well as complexities of management of these patients. Case Presentation: A 50-year-old male with a prior right abdominal stab wound requiring exploratory laparotomy 20 years ago presented with worsening dyspnea on exertion and palpitations. Physical examination was remarkable for jugular venous distention, lower extremity edema, and a pulsatile mass in the right abdomen with an audible bruit. A 12-lead ECG showed rapid atrial flutter. A transthoracic echocardiogram (TTE) showed a reduced left ventricular ejection fraction (LVEF) of 30-35%, severely dilated atria and inferior vena cava (IVC) with high velocity flow. Abdominal computed tomography venogram showed dilation of the IVC up to 8cm and an aortocaval fistula at the level of the right renal vessels, resulting in an atrophic right kidney. Cardiac catheterization was notable for a cardiac output (CO) of 12L/min, cardiac index (CI) of 7L/min/m2 and reduced systemic vascular resistance (SVR). He was managed with beta blockers and diuretics, followed by TEE-guided cardioversion for atrial flutter to restore sinus rhythm. Vascular surgery performed a successful, first of its kind endovascular repair of the abdominal aorta with stenting of the right common iliac artery and placement of a 20mm Amplatzer Septal Occluder device in the right renal artery. He tolerated the procedure well, and post-operative TTE showed a recovered LVEF of 55-60% and CO of 6L/min. Discussion: HOHF is defined by a CO more than 8L/min or CI more than 4L/min/m2 along with clinical symptoms. Decreased SVR leads to sympathetic activation and stimulation of the renin-angiotensin-aldosterone system, leading to fluid retention, cardiac remodeling, and exacerbation of symptoms. Challenges present in the management of HOHF and the use of vasodilatory agents should be avoided, as they can exacerbate the problem. In our case, limitations were also faced in the use of many traditional HF therapies due to renal dysfunction as a result of the fistula. Therefore, repair was the only viable long-term solution. Conclusion: This case displays an uncommon etiology of HOHF, emphasizing the need for meticulous evaluation to ensure proper management. Early detection of aortocaval fistulas is crucial to prevent worsening cardiac dysfunction, with symptoms resolving rapidly post-repair.

A Man with Sudden Onset Leg Pain and Weakness.

An 89-year-old male who had been holding dabigatran in the setting of transcarotid artery revascularization presented to the emergency department with sudden onset leg pain and weakness. Computed tomography angiography revealed acute aortic occlusion and thrombosis of the bilateral common iliac arteries. He underwent aortoiliac and femoral embolectomies and stenting of the bilateral common iliac arteries and returned to his baseline functional status. Acute aortic occlusion is a rare but often devastating vascular emergency characterized by obstruction of the aorta by an embolus or thrombosis. Diagnosis can be challenging as it may be mistaken for spinal pathology, which can lead to delays in diagnosis. Despite advances in diagnostic modalities and interventions, acute aortic occlusion often results in high rates of major morbidity and mortality.

Hybrid aorto-iliac reconstruction for acute infrarenal aortic occlusion: A case report.

Acute aortic occlusion (AAO), though rare, carries a high morbidity and mortality risk. Rapid recognition and revascularization are crucial for limb and life preservation. We present a case of a hybrid approach using open thrombectomy and endovascular arterial stent grafts in lieu of an open bypass for management of AAO. This case describes a 77-year-old man who presented with new-onset lower extremity pain with associated sensory deficits and was found to have acute infrarenal aortic occlusion. Open femoral cutdown for open thrombectomy and distal embolic protection with endovascular balloon occlusion was combined with aortic and bilateral iliac artery stenting. The patient was discharged home on post-operative day 3 with resolution of his presenting symptoms and remains asymptomatic at 1-month follow-up. This technique of aorto-iliac reconstruction using stent grafts has previously been described in the setting of chronic aorto-iliac occlusive disease; however, its use has not been previously documented in the setting of acute aortic occlusion. This case illustrates the safety and feasibility of a hybrid approach to AAO, particularly in patients who are physiologically unfit for open revascularization.

Results from a multicenter retrospective study of transradial iliac artery stenting in Japan.

Large-scale multicenter studies demonstrating the safety and effectiveness of transradial iliac artery stenting are lacking. We evaluated the data from a multicenter database in Japan. Transradial iliac artery stenting was performed on 115 lesions in 105 patients. The approach site was determined at the discretion of the operator. Patients with scheduled multiple sheath insertions for the bidirectional approach were excluded. Clinical data were retrospectively analyzed. The average age of this cohort was 71.1 ± 8.3years. Eighty-six patients (81.9%) were male. Diabetes mellitus, hypertension, dyslipidemia, and smoking habit were present in 39 (37.1%), 84 (80.0%), 69 (65.7%), and 78 patients (74.3%), respectively. Rutherford classifications 1, 2, 3, 4, and 5 comprised 40 (34.8%), 42 (36.5%), 28 (24.3%), 3 (2.6%), and 2 (1.7%) lesions, respectively, while Trans-Atlantic Inter-Society Consensus II classifications A, B, C, and D comprised 74 (64.3%), 21 (18.3%), 15 (13.0%), and 5 (4.3%), respectively. Twenty-seven lesions (23.5%) had chronic total occlusion. All lesions were successfully treated with 141 stents. Four patients (3.8%) required additional puncture of the common femoral artery for successful stent implantation. The ankle-brachial index significantly improved from 0.65 ± 0.17 to 0.95 ± 0.15 (P < 0.0001). None of the patients experienced any procedural or access site-related complications. Asymptomatic radial artery occlusion was observed in three cases (2.9%) after the procedure. There were no target lesion revascularizations or complications at 1month. Compared to the traditional transfemoral approach, transradial iliac artery stenting is safe and feasible without any specific complications in carefully selected patients.

Cook Zenith Alpha Endograft: A Protocol to Minimise Limb Graft Occlusion

Numerous articles have reported an increased incidence of limb graft occlusion (LGO) with the Cook Zenith Alpha endograft compared with other endografts in endovascular aortic aneurysm repair (EVAR). The present study aimed to assess the rate of LGO after EVAR in particular with the Cook Zenith Alpha device when adhering to a standardised protocol designed to prevent limb related complications. This was a non-sponsored retrospective study performed in two university vascular surgery centres employing the same protocol for limb complication prevention during EVAR from 2016 to 2019. The protocol encompassed: (1) angioplasty of any common or external iliac artery with > 50% stenosis before endograft navigation; (2) proximal sealing zone of limbs at the same level of the flow divider with minimum overlap, which is more restrictive than the Cook Zenith Alpha instructions for use; (3) semi-compliant kissing ballooning of limbs; (4) limb stenting for any residual tortuosity, kinking, or stenosis; and (5) adjunctive common and external iliac stenting for residual stenosis or dissection after EVAR. Patients enrolled in this study were treated with standard aortobi-iliac EVAR. Follow up was performed by clinical visit and duplex ultrasonography at discharge, six months, and yearly thereafter. The primary endpoint was to evaluate the LGO rate with different EVAR devices (Cook Zenith Alpha, Gore C3, and Medtronic Endurant) and to determine potential risk factors for LGO associated with the Zenith Alpha. In the study period, 547 EVARs were considered: 233 (42.6%) Cook Zenith Alpha, 196 (35.8%) Gore Excluder,and 118 (21.6%) Medtronic Endurant. The mean follow up was 44 ± 23 months, and the five year freedom from LGO was 97 ± 3%, without differences between groups (97 ± 2%, 95 ± 3%, and 100% with Cook Zenith Alpha, Medtronic Endurant, and Gore Excluder, respectively; p= .080). In the Zenith Alpha group, intra-operative adjunctive iliac artery angioplasty, iliac artery stenting, or iliac limb stenting was performed in 8%, 3.4%, and 9.7% of cases, respectively. Analysis of potential risk factors for LGO identified external iliac artery distal landing and large main bodies (ZIMB 32 - 36) to be independently associated with LGO during follow up (hazard ratio [HR] 18, 95% confidence interval [CI] 3 - 130, p= .004; and HR 12, 95% CI 1.2 - 130, p= .030, respectively). The present experience with a protocol for limb complication prevention allows achievement of a low rate of LGO at five years with Zenith Alpha endografts similar to other endografts. Specific risk factors for the Cook Zenith Alpha endograft are external iliac artery distal landing and the use of a large main body (ZIMB 32 - 36).

Covered Endovascular Reconstruction of the Iliac Artery Bifurcation (CERIB).

The aim of this study was to present the covered endovascular reconstruction of the iliac artery bifurcation (CERIB) technique as a revascularization option for aorto-iliac occlusive disease (AIOD) involving the iliac artery bifurcation. This was a retrospective single-center study including all patients undergoing a CERIB procedure from January 2021 until December 2022. Covered endovascular reconstruction of the iliac artery bifurcation procedures were performed percutaneously with bilateral femoral access, excepting cases where simultaneous open femoral artery reconstruction was required due to the extension of peripheral arterial occlusive disease. Standard patient, procedural, and follow-up (FU) data including survival and arterial reinterventions were gathered and analyzed. A total of 13 patients were included (11/13 male, median age=70 [60-76] years). Additional open and/or endovascular procedures included endarterectomy of the femoral bifurcation (n=6), rotational atherectomy (n=2), and 1 axillary artery cutdown for upper limb access (n=1). Median operating time was 2.9 hours (1.5-4.9 hours); median radiation duration and dose were 28.4 (14.3-63.3 minutes) and 4090.6 (384.4-9430.1 cGray/cm2), respectively. The stent grafts used for CERIB were BeGraft peripheral n=31, BeGraft Aortic n=4 and BeGraft peripheral plus n=1 (Bentley InnoMed GmbH, Hechingen, Germany). In 2 patients with prior stenting of the common iliac artery (CIA), only the internal and external iliac arteries (IIA and EIA) were treated in this study, and in 2 cases, additional uncovered stents were required for relining. Technical success was 100%. During a midterm FU (median 18 [4-31] months), 2 patients died from cardiovascular reasons and 1 patient with prior iliac stenting required reinterventions for recurring occlusion. Covered endovascular reconstruction of the iliac artery bifurcation is a straightforward option for treating AIOD involving the iliac artery bifurcation that allows preservation of internal iliac artery perfusion and shows good early and midterm results. Prior iliac artery stenting may be a risk factor for early occlusion after CERIB. Aorto-iliac occlusive disease with involvement of the internal iliac artery is encountered regularly in vascular surgical practice, but the internal iliac artery is often not included in the revascularization strategy. The present article will increase the awareness for the relevance of including the internal iliac artery in revascularization strategies and presents CERIB as another method to be added to the armamentarium of (endo-)vascular surgeons and interventionalists.

Comparing Iliac Artery vs Superficial Femoral Artery Stenting in Claudicants With Respect to Long-term Outcomes and Major Adverse Limb Events

Comparing Iliac Artery vs Superficial Femoral Artery Stenting in Claudicants With Respect to Long-term Outcomes and Major Adverse Limb Events

Recanalization of superficial femoral artery chronic total occlusion through retrograde popliteal approach recanalization of superficial femoral artery chronic total occlusion

PurposeThis retrospective study aims to evaluate the safety, practicality, and efficacy of the independent retrograde popliteal approach for recanalization superficial femoral artery (SFA) occlusions when the bilateral common femoral artery approach is unavailable, such as after endovascular aneurysm repair or common iliac artery stenting. MethodsThis treatment was considered for patients with contralateral iliac artery occlusion, severe iliac tortuosity, or those who had previously undergone endovascular aneurysm repair or common iliac stenting. Patients with SFA lesions extending into the P1–P2 segment of the popliteal artery or with calcification in the P3 segment were excluded. Angioplasty and stenting were conducted via the popliteal artery approach, with hemostasis at the puncture site achieved using an EXOSEAL vascular closure device. Patients were routinely followed up at 3, 6, and 12 months, and annually thereafter. ResultsForty-eight consecutive patients with SFA occlusion who underwent endovascular treatment via the retrograde popliteal artery approach were included in this study. Retrograde puncture of the popliteal artery was successful in all cases. Six-French sheaths were utilized in all procedures. The EXOSEAL vascular closure device was successfully applied in all 48 cases. No instances of pseudoaneurysms, arteriovenous fistulas, major bleeding, or embolic complications were observed. The technical success rate for SFA recanalization was 100 %. All patients experienced clinical improvement. The ankle-brachial index significantly increased from an initial 0.33 ± 0.11 at admission to 0.81 ± 0.19 at discharge (P < 0.001). The mean follow-up period was 25.1 ± 11.7 months. Kaplan-Meier analysis revealed primary patency rates of 82.5 % at 12 months and 71.8 % at 24 months. No patients required major amputation during the follow-up period. ConclusionThe endovascular treatment of SFA occlusions via the independent retrograde popliteal approach is a viable alternative, demonstrating a low incidence of puncture-related complications and a high success rate of recanalization.

Endovascular repair of bilateral isolated common iliac artery aneurysms with unsuitable anatomy utilizing an aortic bifurcated unibody endograft and modified sandwich technique to preserve pelvic blood flow: a case series

Bilateral isolated common iliac artery aneurysms (CIAAs) are rare, and endovascular repair of CIAAs has emerged as an alternative to traditional open surgical repair. The primary goal of therapy is to exclude the aneurysm sac while maintaining perfusion of at least one internal iliac artery (IIA) to prevent pelvic ischemia. Although the iliac branch device (IBD) has improved the feasibility of preserving the IIA, its applicability is limited to a specific subset of aneurysm anatomy. We present a case series of three patients with bilateral isolated CIAAs in whom preoperative CT scans revealed an absence of a landing zone, the diameter of proximal CIA diameter was less than 13.0 mm, and normal diameter of the nonaneurysmal infrarenal aorta, making it challenging to use an IBD alone or a standard bifurcated aortic endograft to provide a proximal landing zone for iliac artery stenting. To overcome the small diameter of the infrarenal aorta, we implanted an aortic bifurcated unibody endograft. Then, we utilized a balloon-expandable covered stent-graft with overdilation as a modified sandwich technique to create an “eye of the tiger” configuration to prevent gutter leakage. The final angiography performed during the procedure revealed successful exclusion of the aneurysms, with blood flow to the right IIA and no type III endoleak. During the postoperative follow-up period, no patients exhibited symptoms associated with pelvic ischemia. There were no endoleaks or sac expansions on the two-year follow-up CT scans, and all external and internal iliac graft limbs were patent. This study demonstrated that a combination of an aortic bifurcated unibody endograft and a modified sandwich technique can effectively treat bilateral isolated CIAAs with certain anatomical constraints.

The Relationship of CHADS2 Score with In-stent Restenosis in Patients Undergoing Iliac Artery Stenting

Objectives: Percutaneous intervention to aortoiliac occlusive disease (AIOD) is an approved choice of treatment instead of open surgery. However, despite improvement stent technology, in-stent restenosis (ISR) still remains a potential problem, especially in long-term follow-up of these patients. CHADS2 score is mainly a risk stratification tool for atrial fibrillation; however, it is found to be associated with the severity of atherosclerosis and worse outcome of percutaneous interventions. Thus, we aimed to interrogate the relationship between CHADS2 score and ISR in patients with stent implantation for AIOD. Methods: This was a retrospective, observational study that included 419 consecutive patients who had successful common iliac artery (CIA) and external iliac artery stent implantation. Post-procedural ISR is evaluated by either ultrasonography or angiography for each patient in the follow-up period. Patients were then divided into two groups ISR (+) and ISR (–). CHADS2 score was calculated for every patient. Results: ISR was detected in 47 out of 419 patients. Patients who had ISR had smaller stent diameter (8.4±0.9 vs. 7.2±2.8, p=0.005) and longer stent length (80 [59–120] mm vs. 59 [39–100] mm, p&lt;0.001) than those without ISR. CHADS2 score was significantly found increased in patients with ISR than those without ISR (2.04 ± 0.98 vs. 1.45±0.93, p&lt;0.001). Chronic obstructive pulmonary disease (COPD) (hazard ratios [HR]: 2.85, 95% confidence interval [CI]: 1.535–5.293, p=0.001), CHADS2 score (HR: 1.571, 95% CI: 1.186–2.081, p=0.002), and decreased stent diameter (HR: 0.582, 95% CI: 0.366–0.926, p=0.022) were found to be independently associated with ISR. Conclusion: Our study demonstrated that COPD, CHADS2 score, and stent diameter were associated with ISR for patients who had successful iliac artery stent implantation. According to our study, this simple and applicable scoring system can be used to predict patients at high risk for ISR.

Choice of hybrid interventions for iliac-femoral arterial lesions

To compare the short-term and long-term outcomes of hybrid interventions after various infrainguinal reconstructions (restoration of blood flow through superficial femoral artery and pulsatile blood flow through deep femoral artery) in patients with iliac-femoral arterial disease. A retrospective analysis included patients after hybrid iliac-femoral interventions between 2014 and 2018. These interventions included stenting of iliac arteries and various open infrainguinal reconstructions. The first group (n=41) consisted of patients who underwent reconstruction of superficial femoral artery, the second group (n=88) - restoration of pulsatile blood flow in deep femoral artery. We analyzed the Rutherford score, perioperative complications, primary patency rates and limb salvage rates after 12 months in both groups. Significant improvement (Rutherford score +3) was achieved in 28 (70%) and 14 (15.9%) patients, respectively (p<0.05). There were no significant between-group differences in the number of postoperative complications. Surgery time was longer in the first group (median 160 and 130 min, respectively, p<0.05). However, intraoperative blood loss was similar. Primary patency rates after 12 months were 82.4% and 95.1%, respectively (p=0.054). Limb salvage rates after 12 months were 94.7% and 100%, respectively (p<0.05). This study highlights the potential advantages of restoring pulsatile blood flow through the deep femoral artery in hybrid interventions. Higher primary patency and limb salvage rates in the second group indicate better long-term outcomes after restoration of blood flow through the deep femoral artery. Further prospective studies are needed to confirm these results and determine the underlying mechanisms of differences.

“Catheter Kissing” Technique to Recanalize Chronic Total Occlusions in Iliac Artery with Wire-Catheter Approach

PurposeTo describe a technique in which two 5-F curved catheters were utilized to facilitate the wire-catheter approach for recanalizing chronic total occlusions (CTOs) in the iliac arteries concurrently affecting the common iliac artery and external iliac artery. MethodsThis was a single-center retrospective analysis involving endovascular recanalization of 17 iliac artery CTOs in 15 patients (mean age: 73.66 years; all men) between January 2019 and October 2022 using the subintimal arterial flossing with antegrade–retrograde intervention technique. With antegrade and retrograde guidewires in the subintimal spaces of CTOs, the location where the two guidewires seemed to overlap was identified as the rendezvous point. Although the two guidewires appeared to be in close proximity, there was no evidence that the bidirectional subintimal channels were connected. If several initial attempts failed, two 5-F multipurpose catheters were introduced to the rendezvous point, followed by twisting, pulling, and pushing maneuvers until the tips of the catheters touched, indicating that the bidirectional subintimal channels were joined. A second wire rendezvous attempt was then employed to create a flossing-type guidewire. Outcome measurements included technical success, rendezvous points, complications, and procedure duration. ResultsAmong this cohort, 80.0% smoked and 66.7% had hypertension. In 11 limbs (64.7%), when initial wire rendezvous attempts failed, the "catheter kissing" technique was employed to successfully recanalize iliac artery CTOs, taking an average of 3.80 ± 1.64 minutes to complete the secondary wire rendezvous. The average length of CTOs was 111.06 ± 9.99 mm, with 7 (41.2%) and 8 (47.1%) cases exhibiting severe calcification and flush occlusion, respectively. The wire rendezvous point for all cases was in EIA and the average time for successful secondary wire rendezvous was 3.80 ± 1.64 minutes. All patients were treated with iliac artery stents. No statistically significant difference was observed between the puncture sites of the common femoral artery and superficial femoral artery in relation to failure of the primary wire rendezvous (p = 0.644). No in-hospital deaths or complications were associated with the procedure, including iliac artery rupture, distal embolization, or access site complications. ConclusionIn patients with extensive iliac artery CTOs, the "catheter kissing" technique may offer an effective and time-efficient recanalization approach, without requiring additional specialized devices. Importantly, the risk of complications remains unchanged even when employing a wire rendezvous in a challenging subintimal space.

The sandwich technique to treat aortoiliac aneurysms: How to size the parallel graft.

The current gold standard of treatment aortoiliac aneurysms are through endovascular aneurysm repairs which can result in occluding the internal iliac artery. An alternative that preserves internal iliac artery blood flow is the sandwich technique. This is when two covered stents of the internal and external iliac arteries are placed inside the main limb of common iliac artery stent. The complexity of such task is complicated by efficiently calculating the size of the stent grafts to ensure a proper fit. We have developed a mathematical proof that depends on the arterial circumferences to size the three stents needed for the sandwich technique: . D is the diameter of the common iliac stent, d1 and d2 is the diameter of the internal and external iliac artery stent. We added 2mm to account for the thickness of stents. We have treated 10 common iliac artery aneurysms using this formula. Patients were followed up by CTA scans three, six and twelve months after the procedure. Seven of ten had complete sealing and no type III endoleaks intraoperatively. The other three had a small, limited type III endoleak at completion angiogram, that disappeared completely on the three months follow-up. At one-year follow up only one patient developed moderate claudication and erectile dysfunction. ST is considered a practical and feasible approach, as it is easy to implement and can be utilized in most cases, especially in emergencies. It is also cost effective due the use of standard grafts without the need for specialized stents. Our aiming by improving this surgical technique is that we will be able to help standardize practice leading to reduced waste, maintain longer-term repair and therefore reduce complication risks.

310 Rare Elusive Cause of Significant Haematuria – Case Series and Review of Literature

Abstract Arterioureteral fistula (AUF) is a direct communication between the ureter and an artery and is a rare cause of catastrophic, life-threatening haematuria. Fistulation may occur between the ureter and the abdominal aorta, common iliac, external and internal iliac and inferior mesenteric arteries and is typically observed in patients with a prior history of pelvic radiotherapy, oncological pelvic surgeries, aortoiliac vascular procedures and pelvic exenteration. As AUF is so rarely encountered in clinical practice, the urologist may fail to appreciate its presence until late in the patient’s presentation. We are presenting case series as well as review of literature. Patient number 1 presented with repeated episodic large volume haematuria in whom the cause of symptoms remained persistently elusive despite repeated imaging. An eventual diagnosis of a secondary right internal iliac - ureteral fistula was ascertained on a subsequent Digital Subtraction Angiography of the renal tract. The fistula was embolised using an endovascular approach. The patient remained stable post emobilisation and was successfully discharged. Patient number 2 presented with haematuria from her ileal conduit. Initially the cause of symptoms was thought to be due to ureteric stents. During change in her stents, brisk bleeding led to further investigation including iliac angiogram confirming bleeding from left common iliac artery. She had covered common iliac artery stent which successfully controlled her bleeding. These cases emphasise the diagnostic difficulty of AUF, outlines the management principles of this rare disease and aims to increase awareness of this rare yet potentially lethal phenomenon amongst practitioners of urology and interventional radiology.

Endovascular treatment of re-stenotic iliac artery stents with drug-eluting balloons.

To evaluate the results of revascularization of stenotic iliac stents using drug-eluting balloons (DEBs). Seventy-four patients with various levels of iliac stent restenosis were enrolled to study. All restenotic stents were treated using paclitaxel-coated balloons. Through a follow-up median period of 24months (4-24months), there were no in-stent re-restenosis in 55 patients (74.3%) and there was one in class 1 (1.4%), four in class 2 (5.4%), and fourteen in class 3 (18.9%). We conclude that; DEBs can be used for restenotic iliac artery stents for some Type C and D lesions, in addition to Types A and B with satisfacting results.