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Published on: September 22, 2020
Predicting outcome of angioplasty and selective stenting of multisegment iliac artery occlusive disease
R J Powell1, M Fillinger, D B Walsh
1Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
Insights
The external iliac artery's disease severity predicts outcomes for patients undergoing angioplasty and stenting for multisegment iliac occlusive disease. Extensive external iliac disease indicates a higher likelihood of treatment failure.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Cardiovascular Disease
Background:
- Multisegment iliac occlusive disease often requires reintervention to maintain arterial patency.
- Predictors and causes of endovascular treatment failure remain largely unknown.
- Identifying factors for successful iliac angioplasty and stenting is crucial for long-term patient outcomes.
Purpose of the Study:
- To identify arteriographic predictors of angioplasty and selective stent failure.
- To evaluate the impact of lesion morphology on treatment outcomes in multisegment iliac occlusive disease.
- To stratify patients based on disease extent for predicting endovascular therapy success.
Main Methods:
- Scoring of iliac segments (common and external) using a modified Society of Cardiovascular and Interventional Radiology classification in 75 patients.
- Calculation of total and external iliac scores based on lesion severity.
- Review of arteriograms to assess lesion recurrence, location, and previous interventions.
Main Results:
- Recurrence predominantly occurred at sites of previous endovascular intervention (75%).
- External iliac artery disease severity (score ≥3) was an independent predictor of failed endovascular therapy.
- Patients with less severe external iliac disease (score ≤2) demonstrated significantly higher patency rates and improved clinical outcomes compared to those with extensive disease.
Conclusions:
- Lesion formation after treatment for multisegment iliac occlusive disease commonly occurs in previously treated areas.
- The external iliac artery score effectively stratifies patients for predicting durable results from endovascular treatment.
- Patients with extensive external iliac disease (score ≥3) experience poor outcomes with angioplasty and stenting, warranting investigation into alternative initial therapies.
Background:
Patients who require angioplasty and stenting of multiple iliac arterial segments often require reintervention to maintain long-term patency. Morphologic predictors and causes of failure are unknown. The purpose of the current study was to define arteriographic predictors of angioplasty and selective stent failure in the treatment of multisegment iliac occlusive disease.
Methods:
All iliac segments (two common and two external) of 75 patients who underwent angioplasty and selective stent placement for multisegment iliac occlusive disease (>/= two segments) were scored through use of a modification of the Society of Cardiovascular and Interventional Radiology classification for iliac angioplasty (0 = no lesion; 4 = most severe). Total iliac score was calculated by summing scores from each segment. A separate external iliac score was calculated by adding only the external iliac scores. Arteriograms were reviewed initially and at the time of lesion recurrence and stratified by lesion location and previous intervention.
Results:
The area of previous endovascular intervention was the site of recurrence in 75% of patients. New lesions, presumably a result of progressive atherosclerosis, occurred in 15% of patients, and lesions occurred in both new and previously treated iliac segments in 10% of patients. Only the external iliac score was an independent predictor of failed endovascular therapy despite reintervention. For patients with an external iliac score of 2 or less, the endovascular primary-assisted patency rates at 6, 12, and 24 months were 96%, 92%, and 89%, respectively. This was improved in comparison with the 90%, 63%, and 45% patency rates observed in patients with an external iliac score of 3 or more (P =.001). Patients with an external iliac score of 3 or more had a significantly lower incidence of hemodynamic and clinical improvement after intervention and a threefold higher need for surgical inflow procedures than patients with an external iliac score of 2 or less.
Conclusions:
Lesion formation after treatment of multisegment iliac occlusive disease typically occurs in areas of prior intervention. The extent of external iliac disease can be used to stratify patients with multisegment iliac occlusive disease who will likely respond to endovascular treatment with a durable result. Patients with extensive external iliac disease (score >/= 3) have poor results after angioplasty and selective stenting as applied in this study, even with endovascular reintervention. They are ideal subjects for prospective comparative studies of competing initial therapies, including stenting, endografting, and aortobifemoral bypass grafting.
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