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Early results of stent-grafting to treat diffuse aortoiliac occlusive disease
Eva M Rzucidlo1, Richard J Powell, Robert M Zwolak
1Department of Surgery, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756, USA.
Insights
Iliac artery stent-grafting shows promising early results for diffuse aortoiliac occlusive disease, with improved patency when combined with common femoral endarterectomy. This procedure offers an alternative to surgical bypass grafting.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Interventions
Background:
- Diffuse aortoiliac occlusive disease and long external iliac artery occlusions traditionally require surgical bypass grafting due to limited stent durability.
- Stent-graft placement is evaluated as a less invasive treatment option for these challenging vascular conditions.
Purpose of the Study:
- To assess the efficacy and durability of stent-graft placement for treating diffuse aortoiliac occlusive disease or isolated external iliac artery occlusions.
- To compare stent-graft outcomes with historical data from surgical bypass and stenting alone.
Main Methods:
- Retrospective analysis of 34 patients undergoing iliac artery stent-grafting for severe limb ischemia.
- Evaluation of technical, hemodynamic, and clinical success rates using Society for Vascular Surgery/American Association for Vascular Surgery criteria.
- Assessment of aortoiliac primary and secondary patency rates at 12 months, with a focus on the impact of concomitant common femoral endarterectomy.
Main Results:
- Successful stent-graft placement was achieved in all cases where wire crossing was possible, leading to improved ankle-brachial index.
- At 12 months, primary patency was 70% and primary assisted patency was 88%.
- Primary patency failures were significantly higher in patients without concomitant common femoral endarterectomy, suggesting its importance in improving durability.
Conclusions:
- Stent-graft placement demonstrates encouraging early results for diffuse aortoiliac occlusive disease, potentially superior to stenting alone.
- Concomitant common femoral endarterectomy or meticulous assessment of femoral artery disease is crucial for enhancing the long-term durability of iliac stent-graft procedures.
Introduction:
Diffuse aortoiliac occlusive disease or isolated external iliac artery occlusion >or=10 cm long typically are treated with surgical bypass grafting because of limited durability of stent placement. We evaluated the results of stent-graft placement as an option for treatment of these diseases.
Methods:
Demographic data for patients undergoing stent-grafting in one or more iliac artery segments were recorded. Technical, clinical, and hemodynamic success, and aortoiliac primary and secondary patency were analyzed with Society for Vascular Surgery/American Association for Vascular Surgery criteria.
Results:
Thirty-four consecutive patients underwent stent-graft treatment because of rest pain (65%) or tissue loss (35%). Mean patient age was 63 years, and 38% of patients were women. Ninety-one percent of patients had hypertension, 71% had coronary artery disease, 21% had renal insufficiency (serum creatinine > 2.0 mg/dL), and 26% had diabetes; 71% were active smokers. TransAtlantic Inter-Society Consensus C or D disease was present in 85% of patients, complete common or external iliac artery occlusion was present in 41%, and external iliac artery disease requiring treatment was present in 94% of patients. Mean lesion length was 13.7 +/- 8 cm. Technical, hemodynamic, and clinical success was achieved in all patients in whom the lesion could be crossed with a wire. Ankle-brachial index increased from.30 +/-.03 to.59 +/-.04. Self-expanding stent grafts were used (Wallgraft, Boston Scientific, Boston, Mass, in 88% of patients; Viabahn, W. L. Gore, Flagstaff, Ariz, in 12% of patients). Concomitant common femoral endarterectomy was performed in 53% of patients. At 12 months, primary patency was 70% and primary assisted patency was 88%. Four stent grafts became occluded because of distal external iliac artery or proximal common femoral artery disease, which required subsequent common femoral endarterectomy and either external iliac artery stent grafting or extraanatomic bypass grafting. Eighty percent (four of five) of primary patency failures were in patients who did not undergo concomitant common femoral endarterectomy at initial stent graft placement.
Conclusion:
Early results of stent-graft placement to treat diffuse aortoiliac occlusive disease appear better than our recent experience with stenting alone. Concomitant common femoral endarterectomy or better assessment of femoral disease may improve durability.