Stent implantation strategy of endovascular treatment in aortoiliac occlusive disease / 国际外科学杂志

Aortoiliac occlusive disease is a group of ischemic disease caused by stenosis or occlusion of infrarenal aorta and iliac artery. Gluteus or lower extremity intermittent claudication and even limb-threatening ischemia are most common symptoms. With the development of endovascular devices and techniques, therapeutic options of complex lesions have changed from open surgery to endovascular treatment, which have the advantages including satisfied patency rate, less perioperative complications and fast recovery. This article will review and summarize stent implantation choices and techniques for endovascular treatment in aortoiliac occlusive disease.

Tratamiento endovascular de la enfermedad obstructiva aortoilíaca / Endovascular management of aortoiliac occlusive disease

Resumen Introducción: La angioplastia transluminal percutánea (ATP), se ha convertido en una técnica aceptada, en el tratamiento de la enfermedad obstrutiva aortoilíaca, con tasas de éxito del 90-92% y permeabilidad primaria del 55-72% a 5 años. Objetivo: Evaluar los resultados del tratamiento endovascular del sector aortoilíaco. Material y Método: Estudio descriptivo, retrospectivo (revisión de serie de casos unicéntrica), de pacientes, sometidos consecutivamente al tratamiento endovascular (ATP simple y ATP con stent) de la patología obstructiva del sector aortoilíaco, durante un período de 7 años (2002-2019), en el Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Se realizaron 103 procedimientos en 94 pacientes, sexo masculino: 63,83%, femenino: 36,17%, edad promedio: 67,4 años (rango 47-96), distribución de las lesiones según la clasificación TASC II: A (46,24%), B (39,78%), C (8,60%), D (5,38%), remodelando la biburfaccción aórtica (kissing stent) en un 6,80%, procedimientos híbridos (12,62%), seguimiento promedio (47,13 meses), éxito clínico (90,29%), exito técnico (94,17%), permeabilidad primaria, primaria asistida y secundaria a 5 años del 68,09%, 75,53% y 81,91% respectivamente, tasa de salvación de la extremidad a 5 años del 84,04%, mortalidad < 30 días del 1,94%, supervivencia a 5 años del 90,42%. Discusión: Las técnicas endovasculares del sector aortoilíaco son fiables, sus resultados ténicos y permeabilidad, están influenciados por el estadio clínico del paciente y severidad de las lesiones tratadas. Conclusión: En pacientes adecuadamente seleccionados, el tratamiento endovascular del sector aortoilíaco presenta excelentes resultados, permitiendo aumentar la indicación de tratamiento en pacientes considerados de alto riesgo.

Introduction: Percutaneous transluminal angioplasty (PTA) has become an accepted technique in the treatment of aortoiliac occlusive disease, with success rates of 90-92%, and primary patency of 55-72% at 5 years. Aim: To evaluate the results of endovascular treatment (PTA or PTA with stents) of the aortoiliac sector. Material and Method: Descriptive, retrospective study (single-center case series) of patients, consecutively subjected to endovascular treatment (PTA or PTA with stents) of aortoiliac occlusive disease, during a period of 7 years (2002 - 2019), at the Dr. Eduardo Pereira Hospital in Valparaíso, Chile. Results: 103 procedures were performed in 94 patients, male: 63.83%, female: 36.17%, mean age: 67.4 years (range 47-96), distribution of the lesions according to the TASC II classification: A (46.24%), B (39.78%), C (8.60%), D (5.38%), remodeling the aortic bifaction (kissing stent) in 6.80%, hybrid procedures (12.62%), average follow-up (47.13 months), clinical success (90.29%), technical success (94.17%), primary patency, assisted primary and secondary at 5 years of 68.09%, 75, 53% and 81.91% respectively, 5-year limb salvage rate of 84.04%, mortality < 30 days of 1.94%, 5-year survival of 90.42%. Discussion: Endovascular techniques in the aortoiliac sector are reliable, their technical results and patency are influenced by the clinical stage of the patient and the severity of the lesions treated. Conclusion: In appropriately selected patients, endovascular treatment of the aortoiliac sector, presents excellent results, allowing an increase in the indication for treatment in patients considered to be at high risk.

Treatment Strategy for Leriche Syndrome Complicated with Ischemic Heart Disease / 日本心臓血管外科学会雑誌

Leriche syndrome is often complicated with ischemic heart disease (IHD). In such cases, as the internal mammary artery (IMA) supplies blood to the lower-limbs through a collateral network, coronary artery bypass grafting (CABG) using IMA is considered to worsen the lower-limb ischemia and use of intra-aortic balloon pumping prior to lower limb revascularization is not possible. Recent advances in endovascular technology enable us to perform endovascular treatment (EVT) even in Leriche syndrome. In 3 patients diagnosed with Leriche syndrome associated with IHD, tailor-made treatments were performed as one-stage or two-stage surgeries. Various techniques such as percutaneous coronary intervention (PCI), CABG, and open surgical revascularization or EVT of lower limbs were employed. EVT is a less invasive and more attractive alternative to open surgical revascularization, it led to new treatment options in patients with this particular circumstance. Considering the severity of pathophysiology, treatment strategy should be determined on a case-by-case basis.

Progress in endovascular therapies of TASC Ⅱ D aortoiliac occlusive disease / 国际外科学杂志

Aortoiliac occlusive disease is a common and frequently-occurring disease of vascular surgery,and atherosclerosis is the main cause of its disease.Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC Ⅱ) D type of aortoiliac occlusive disease due to complex lesions,the preferred treatment method is aortobifemoral bypass.With the change of treatment concept,in-depth study of kiss stent,and the introduction of reconstruction of aortic bifurcation and integrated stent technology,endovascular therapies has achieved satisfactory short-term and long-term patency rates.At present,endovascular therapies has become the preferred treatment for TASC Ⅱ D aortoiliac occlusive disease.This article reviews the recent advances in endovascular therapies of TASC ⅡD aortoiliac occlusive disease.

Endovascular therapy with covered stent for aortoiliac occlusive disease:clinical effect in 20 patients / 介入放射学杂志

Objective To evaluate the clinical effect of endovascular therapy with covered stent in treating aortoiliac occlusive disease. Methods The clinical data of 20 patients with aortoiliac occlusive disease, who received endovascular therapy with covered stent during the period from January 2014 to December 2016, were collected. According to Rutherford standard of clinical symptom classification, gradeⅢ, grade Ⅳ and grade V were seen in 9, 7 and 4 patients respectively. Based on the Trans-Atlantic Society Coalition (TASC) treatment guidelines Ⅱ classification, B type, C type and D type were observed in 4, 7 and 9 patients respectively. The postoperative primary patency and secondary patency of the stent as well as the clinical efficacy were analyzed. Results Endovascular treatment was successfully accomplished in all 20 patients. After the treatment, the clinical symptoms were significantly relieved. Two patients developed complications (10％). One patient developed thrombus at the distal end of stent, which was improved after thrombolytic therapy. Another patient developed hematoma at puncture site, which was absorbed after conservative therapy. No perioperative death occurred. The patients were followed up for 5-37 months, with a mean of (17±10) months. The primary patency rate was 95％ and the secondary patency rate was 100％. Conclusion For the treatment of aortoiliac occlusive disease, endovascular therapy with covered stent has excellent clinical efficacy.

Effect of Percutaneous Transluminal Angioplasty Combining Thrombolysis on Ankle Brachial Index in Patients With Aortoiliac Stenosis or Occlusive Disease / 中国循环杂志

Objectives: To explore the effect of percutaneous transluminal angioplasty (PTA) combining thrombolysis on ankle brachial index (ABI) in patients with aortoiliac stenosis or occlusive disease (ASOD). Methods: A total of 100 ASOD patients treated in our hospital from 2012-06 to 2015-06 were enrolled. According to treatment method, the patients were divided into 2 groups: Traditional surgery group and PTA combining thrombolysis group. 50 in each group. Results: Compared with Traditional surgery group, PTA combining thrombolysis group had the less intra-operative bleeding, shorter bed time, hospital stay time and the lower complication rate. ABI, walking distance were improved after the operation in both groups and they were better in PTA combining thrombolysis group than Traditional surgery group, P<0.001. The 1, 2, 3 years total patency rates and limb salvage rates were similar between 2 groups, P>0.05. Conclusions: PTA combining thrombolysis method had good short- and long-term efficacy for treating ASOD; it may reduce surgical trauma and complications, should be beneficial to future recovery in relevant patients.

The Results of Self-Expandable Kissing Stents in Aortic Bifurcation

PURPOSE: Kissing stent reconstruction is a widely used technique for the management of aortoiliac occlusive disease involving the aortic bifurcation or proximal common iliac arteries. The purpose of this study was to evaluate the results of self-expandable kissing stents in the aortic bifurcation. METHODS: We reviewed medical records of the patients treated with a kissing stent retrospectively from January 2007 to December 2012. The primary and secondary patencies were determined with Kaplan-Meier analysis, and Cox regression was used to determine the factors associated with patency. RESULTS: A total of 21 patients were included, and all were male (median age 53+/-15 years, range 48-78 years). Major symptoms were claudication (n=16, 61.9%), rest pain (n=5, 23.8%) and gangrene (n=5, 23.8%). Tans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II classification was A 2 (9.5%), B 5 (23.8%), C 7 (33.3%) and D 8 (38%). The mean follow-up was 40.7 months. Major complication occurred in only one case which consisted of distal limb ischemia by emboli. Six patients developed symptomatic restenosis or occlusion. There was no major amputation, but minor amputation occurred in 3 patients. There were 2 mortalities not associated with the procedure (lung cancer and intracranial hemorrhage). Primary patency was 89.6% at 1 year, 74.7% at 3 years and 64.0% at 5 years. Secondary patency was 94.1% at 1 year, 88.2% at 3 years and 68.6% at 5 years. No risk factors for restenosis or occlusion were identified. CONCLUSION: Self-expandable kissing stents can be used successfully with comparable patency for endovascular treatment of symptomatic atherosclerotic occlusive lesions in the aortic bifurcation area.

A review of endovascular treatment of aortoiliac occlusive disease / 国际外科学杂志

To review the outcome of the endovascular treatment of aortoiliac occlusive disease,the recent literature concerning endovascular treatment as well as aortoiliac occlusive disease was extensively reviewed,and the research and development were summarized.The results are:(1) In most cases,endovascular invention is better than surgery ; (2) Stent placement has a higher technical success rates and a better longterm outcome than percutaneous transluminal angioplasty,primary or selective stent placement,which is better,is controversial; (3)Covered stents perform better than bare stents in longer-term patency and clinical outcome ; (4)Endovascular treatment of complex AIOD provides excellent early and long-term results,similar to those obtained in the treatment of simple lesions.So,in general,endovascular treatment of aortoiliac occlusive disease provides excellent clinical results,further research is needed.

A Case of Complex Restenosis of Aortoiliac Stent Mimicking Downward Stent Migration

We present the case of aortoiliac stent restenosis which was caused by 13 years' of neointimal progression within and at the edge of the aortoiliac stent at the iliac bifurcation. A 74 year-old man presented with vertigo. We planned 4-vessel cerebral angiography through the right common femoral artery to evaluate his carotid artery but failed due to the catheter jam against the struts of the previously deployed aortoiliac stent. Retrograde sheath angiography through the right femoral artery indicated that the previously implanted stent seemed to have migrated in a downward direction and be embedded in the internal iliac artery. While comparing with the previous angiograms, we found that the implanted stent did not migrate downwardly but was separated from the external iliac artery by newly formed septum of neointimal hyperplasia. We successfully reopened the stenosis using the contralateral approach after widening the struts of the previously deployed T-stents.

Ten year outcomes after bypass surgery in aortoiliac occlusive disease / 대한외과학회지

PURPOSE: Most outcome studies of bypass surgery are limited to five years of follow-up. However, as human life expectancy has increased, analyses of more long-term outcomes are needed. The aim of this study is to evaluate 10-year outcomes of anatomical bypasses in aortoiliac occlusive disease. METHODS: From 1996 to 2009, 92 patients (82 males and 10 females) underwent aortic anatomical bypasses to treat aortoiliac occlusive disease at Samsung Medical Center. The patients were reviewed retrospectively. Kaplan-Meier survival analyses were performed using PASW ver. 18.0 (IBM Co). RESULTS: A total of 72 patients (78.3%) underwent aorto-femoral bypasses (uni- or bi-femoral), 15 patients (16.3%) underwent aorto-iliac bypasses (uni- or bi-iliac), and 5 patients (5.4%) underwent aorto-iliac and aorto-femoral bypasses. The overall primary patency rates of the 92 patients were 86.2% over 5 years and 77.6% over 10 years. The 10-year limb salvage rate and overall survival rate were 97.7% and 91.7%, respectively. CONCLUSION: The overall patency rates of bypass graft and limb salvage rates decreased as time passed. The analysis of results after bypass surgery to treat arterial occlusive disease will be needed to extend for 10 years of follow-up.

The accidental renal artery embolism in patient with aortoiliac occlusive disease with unilateral renal atrophy during aortobifemoral bypass graft: A case report

Aortoiliac occlusive disease occurs commonly in patients with peripheral arterial disease. Aortofemoral bypass is the most common surgical procedure to treat aortoiliac occlusive disease. Intraoperative renal artery embolism is rare complication that may occur during aortofemoral bypass in patients with aortoiliac occlusive disease. It is very important to prevent the risk of subsequent renal artery thrombotic or atheromatous embolism during aortofemoral bypass in patients with juxtarenal aortic occlusion because of accidentally dislodging fragments or atheromatous emboli into the renal arteries. Emboli to one or more major renal arteries are an occasional cause of renal failure. We report a case of renal artery embolism in patient with aortoiliac occlusive disease and unilateral renal atrophy during aortobifemoral bypass graft.

Robot Assisted Aorto-femoral Bypass

Laparoscopic vascular surgery has not been widely embraced by vascular surgeons because of the specific technical skills needed in performing vascular anastomosis. Robot assisted vascular surgery has shown the possibility to overcome several limitations of laparoscopic vascular surgery in previous studies. We report two cases of robot assisted aortofemoral bypass grafting for aortoiliac occlusive disease. Two male patients, 65 and 62 years old were admitted complaining of disabling claudication. CT angiography revealed total occlusion of left iliac artery and bilateral superficial femoral arteries in one case and concentric stenosis of lower abdominal aorta, severe occlusion of left common iliac artery in the other case. Laparoscopic aortofemoral bypass grafting was performed with a proximal end-to-side anastomosis constructed with robotic arms using Dacron graft. Femoral anastomosis was performed in the conventional method. The aortic clamping times were 80 and 198 minutes and operating times were 435 and 605 minutes, respectively. The patients were discharged uneventfully on postoperative days 20 and 13. Robot assisted vascular surgery is a technically feasible and safe procedure.

Cumulative Patency Rate of Percutaneous Transluminal Angioplasty and Stent Placement for Aortoiliac Occlusive Disease

PURPOSE: To evaluate the results of iliac artery angioplasty and stent placement as an option for the treatment of aortoiliac occlusive disease. METHOD: The records of 30 patients (mean age, 65.5 years) who underwent iliac artery angioplasty and/or stent placement were reviewed retrospectively. Presenting symptoms included asymptomatic (6.7%), claudication (73.3%), rest pain (10%), ulceration/tissue loss (3.3%), and blue toe syndrome (6.7%). Follow-up included angioplasty, Doppler ultrasound, and clinical examination. Mean follow-up time was 32 months. RESULT: Forty iliac lesions were treated. Thirty-seven percent of patients had hypertension, 33% had diabetes mellitus, 23% had coronary arterial disease, 6.6% had cerebrovascular disease, 3.3% had hyperlipidemia and 3.3% had renal insufficiency. TASC (Trans Atlantic Inter-Society Consensus) A, B, C and D disease types were 11 (36.7%) patients, 5 (16.7%), 10 (33.3%) and 4 (13.3%). Ipsilateral superficial femoral artery occlusion was present in 6 (20%) patients. Concomitant femoral artery bypass surgery was performed in 10 (33.3%) patients. The cumulative primary patency rates were 83.4%, 71.9% and 64.7% at 1, 2, and 3 years, respectively. CONCLUSION: Iliac artery angioplasty and stent placement is a technically safe and effective treatment modality in patients without ipsilateral superficial femoral artery occlusion.

Expression of Matrix Metalloproteinases and Their Endogenous Inhibitors in Human Abdominal Aortic Aneurysms

PURPOSE: Among the theories in the pathogenesis of abdominal aortic aneurysms, matrix metalloproteinase (MMP)- induced excessive degradation of extracellular matrix protein has been widely recognized. Normally, MMPs keep a balance with their endogenous tissue inhibitors of metalloproteinases (TIMPs). Recently, the MMP-TIMP imbalance has been investigated for potential etiological role in AAA formation. The aim of this study was to define the role of the imbalance between the expressions of the specific MMPs and their physiologic inhibitors (TIMPs) in the formation of human abdominal aortic aneurysm (AAA). METHODS: Aortic tissues from 12 patients with AAAs, 4 age-matched patients with aortoiliac occlusive diseases (AODs), and 6 cadaveric organ donors, as normal controls, were obtained and prepared. The productions and expressions of MMP-2, 9, MT1-MMP and TIMP-1, 2, and 4 were analyzed using gelatin zymography, Western blotting, and immunohistochemistry. RESULTS: In the gelatin zymography, the net matrix-degrading activities were higher in the AAAs and AODs than in the normal control group due to the higher presence of MMP-2 and 9. From the Western blot analysis and immunohistochemistry, those with AAAs and AODs showed significantly higher expressions of MMP-2, 9, and MT1-MMP than the normal control group. However, no differences in the TIMP-1 and 2 expressions were found between the all groups. In contrast, TIMP-4 protein was expressed at a significantly lower level in the AAAs and AODs than in the normal control group. MMP-9/TIMP-1, MMP-2/TIMP-2, and MMP-2/TIMP-4 were significantly different between AAAs and normal control group. From the densitometric analysis of the Western blotting, no significant differences were found in tissue expressions of MMPs and TIMPs between the AAAs and AODs groups, but, in the immunohistochemistry, the AAAs group showed a different distribution of the MMP expression confined to sites of overt medial damage compared with that in the intimal plaque in AODs. CONCLUSION: The imbalance of expression between specific MMPs and their endogenous inhibitors plays an etiological role in the formation of AAAs. In addition, TIMP-4 may suppress the MMP-induced aneurysmal formation. Our results suggest that the eventual formation of aneurysms or occlusive lesions appears not to result from an ongoing difference in the proteolytic activities, but from differences in other factors, as-yet-undefined, including the distribution of MMPs expression within the aortic walls.

A Clinical Analysis of Chronic Aortoiliac Occlusive Disease

Chronic Aorto-Iliac Occlusive Disease (CAIOD) commonly occurs in conjunction with obstruction in the femoral and popliteal arteries, resulting in ischemia of the lower extremities. To analyze the characteristics of CAIOD among Koreans, we relied on 110 cases of aorto-iliac occlusive disease in-patients who underwent operative treatment at Yeungnam university hospital during the last 15 years. Among the 110 total cases, the mean age was 61, with the highest incidence among people in their 60s, followed by those in their 50 s and then in their 70 s. 88.2% of the cases occurred in males with the remaining 11.8% occurring among females. Co-existing diseases included hypertension 46 cases (41.8% of the cases), coronary arterial diseases 17 cases (15.4%), diabetes mellitus 22 cases (20%), chronic pulmonary diseases 14 cases (12.7%) and cerebrovascular diseases 10 cases (9.1%). 80% of the cases involved patients with a history of smoking. The level of serum total cholesterol was higher than normal in 32.7% of cases. Advanced arteriosclerotic manifestation was found in over two-thirds of the cases, with the anatomical distribution as follows: Type I 5 cases (4.5%), Type II 30 cases (27.3%) and Type III 75 cases (68.2%). According to the Fontaine classification of clinical symptoms, the distribution was as follows: Grade I (0 case), Grade II 52 cases (47.3%), Grade III 36 cases (32.7%) and Grade IV 22 cases (20.0%). Among the 110 cases, 75 received only inflow procedures, 19 received both inflow and outflow procedures at the same time, and 16 received only outflow procedures. Among the 94 cases of inflow procedures, PTA accounted for 11 cases, PTA with stent accounted for 5, endarterectomy for 3, and bypass operations for 75. The breakdown for the 75 cases of bypass operations was as follows: aortofemoral or aortoiliac (21 cases): iliofemoral (12 cases): extraanatomic bypass including axillobifemoral bypass (15 cases): and fem-fem bypass (27 cases). Thirty-five outflow procedures included femoropopliteal and femorotibial bypass (22 cases), thromboembolectomy (6 cases), endarterectomy (5 cases) and profundoplasty (2 cases). 19 out of these 35 outflow procedures were performed in conjunction with inflow procedures at the time of the initial operation, but 16 were used without inflow procedure, mainly for Type III cases with relatively mild aortoiliac pathology. In over 90% of the 110 operative cases, the early outcome was good with 3 to 2 rating according to Rutherford criteria. The early outcome seemed to be related to the extent of disease and preoperative clinical symptoms but not with the surgical procedures used. Among the 110 total cases, 26 (23.6%) required second procedures. Among the 94 cases of inflow procedures, 24 (25.5%) required the second procedures, while among the 16 cases of outflow procedures, 2 (12.5%) required the second procedures. Among the 94 cases of inflow procedures, the need for second operations was higher in cases undergoing both inflow and outflow procedure at the same time (36.8%, 7 out of 19 cases) compared to the cases that underwent inflow procedure only (22.6%, 17 out of 75 cases). Among the inflow procedures, axillofemoral (46.7%) and iliofemoral (41.7%) bypass required the 2nd procedures much more frequently than aorto-fem (23.8%), fem-fem (14.8%) bypass and PTA (18.8%). An overall 5-year cumulative patency rate demonstrated significant statistical differences between procedures (p=0.001 Log Rank test): aortofemoral or aortoiliac: 0.81, fem-fem: 0.77, PTA: 0.74, iliofemoral: 0.56, and axillofemoral: 0.50. A 5-year cumulative patency rate also showed a significant correlation with the extent of disease (p=0.01), preoperative ischemic symptoms (p=0.05) and Ankle Brachial pressure Index (ABI.). Operative mortality for the 110 cases was 3.6% (4 cases), including 3 resulting from associated cardiac conditions and 1 resulting from aortoduodenal fistula.

Surgical Treatment of Aortoiliac Occlusive Disease

BACKGROUND: The infrarenal abdominal aorta and the iliac arteries are the most common sites of chronic atherosclerosis in patients with symptomatic occlusive disease of the lower extremities. Direct anatomic reconstruction is the standard surgical treatment for a patient with aortoiliac occlusive disease, but extraanatomic bypass is used in patients with high cardiac or other risks. The purpose of this study was to compare the operative results of direct anatomic reconstruction with those an extraanatomic bypass and to select the optimal surgical treatment according to the preoperative risk. METHOD: The cases of 40 patients who received vascular reconstruction for aortoiliac occlusive disease between January 1995 and October 1997 were reviewed. The patients were classified in two groups: a direct anatomic reconstruction group and an extraanatomic bypass group. Operative risks were analyzed by the scoring system recommended by the Subcommittee on Reporting Standards for Lower Extremity Ischemia of International Society for Cardiovascular Surgery (ISCVS). Graft patency, operative mortality, and morbidity were also analyzed for the two groups. RESULT: There was no significant difference in operative risk (p>0.05) between the two groups, but the result of graft patency was better and the postoperative morbidity was less in direct anatomic reconstruction group. There was no postoperative mortality in either group. CONCLUSION: According to this study, direct anatomical reconstruction was superior to extraanatomic bypass inspite of same operative risks.

Surgical Management of Patients with Coronary Artery Disease and Aortoiliac Occlusive Disease / 日本心臓血管外科学会雑誌

When coronary artery bypass grafting (CABG) is to be done, we use the internal thoracic artery (ITA) as a graft conduit in order to obtain longer patency. When the ITA acts as a good collateral to the lower extremities, blood flow to the extremities may decrease after CABG with ITA. Simultaneous open heart surgery and laparotomy may cause pulmonary complication. We made an algorithm of treatment for patients with coronary artery disease (CAD) and aortoiliac occlusive disease including these problems. From July 1991 to March 1992, 6 patients were operated and reviewed. Four patients were operated on for CAD and AIOD simultaneously. Two patients were operated on for CAD or AIOD at first and for the other secondarily. All 6 cases were discharged without any complications and are now free from angina and intermittent claudication. When the therapeutic plan for the patients with CAD and AIOD is made, it is very important that coronary revascularization is planned at first with careful evaluation of the blood flow to the lower extremities in cases with AIOD.