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Directional atherectomy in iliac stent failure: clinical technique and histopathologic correlation
D F Ettles1, A W MacDonald, P A Burgess
1Department of Radiology, Hull Royal Infirmary, East Yorkshire, United Kingdom.
Insights
Directional atherectomy effectively treats iliac stent stenosis and occlusion, with 92% of patients remaining symptom-free. Histologic analysis reveals multifactorial causes for restenosis, not just myointimal hyperplasia.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Biomedical Engineering
Background:
- Iliac stent stenosis and occlusion are common complications after treatment for occlusive aortoiliac disease.
- Restenosis within iliac stents can lead to recurrent symptoms and reduced quality of life.
- Current treatment options may have limitations in addressing the complex pathology of stent failure.
Purpose of the Study:
- To evaluate the feasibility and effectiveness of directional atherectomy for treating iliac stent stenosis or occlusion.
- To analyze the histologic characteristics of tissue removed during atherectomy from failed iliac stents.
- To compare atherectomy with balloon angioplasty for iliac stent restenosis.
Main Methods:
- Directional atherectomy was performed on 16 iliac stents (6 occluded, 10 stenosed) in 12 patients.
- Low-dose thrombolysis preceded atherectomy in cases of stent occlusion.
- Excised atherectomy specimens were examined histologically; clinical outcomes were assessed via follow-up.
Main Results:
- Successful stent clearance and restored femoral pulses were achieved within 24 hours in all patients, with no major complications.
- 92% of patients remained symptom-free with unlimited walking distance at a mean follow-up of 11.5 months.
- Histology showed a mix of myointimal hyperplasia, intimal fibrosis, atheroma, and organized thrombus.
Conclusions:
- Directional atherectomy is an effective and safe treatment for iliac stent occlusion and restenosis.
- Debulking lesions with atherectomy appears more advantageous than simple balloon angioplasty.
- Stent restenosis and occlusion are likely multifactorial, challenging the sole attribution to myointimal hyperplasia.
Purpose:
To assess the feasibility and efficacy of directional atherectomy in the treatment of iliac stent stenosis or occlusion and to evaluate the histologic composition of excised atherectomy specimens.
Methods:
Directional atherectomy of six occluded and 10 severely stenosed iliac stents was undertaken in 12 patients at a mean interval of 28 months (range 3-69 months) after stent insertion for occlusive aortoiliac disease. In cases of stent occlusion, atherectomy was preceded by low-dose thrombolysis. In all patients stent clearance with return of femoral pulses was achieved within 24 hr and there were no significant complications. All excised specimens were sent for histologic examination.
Results:
Eleven patients (92%) remain symptom free with unlimited walking distance at a mean follow-up interval of 11.5 months (range 3-31 months) after treatment. Histologic examination revealed typical myointimal hyperplasia at three excision sites, intimal fibrosis at three sites, atheroma at four sites and organized thrombus at six sites.
Conclusion:
Atherectomy offers an effective treatment in iliac stent occlusion and restenosis with no significant adverse effects. Debulking of these lesions seems to offer a more logical approach than simple balloon angioplasty. Clinical and duplex follow-up confirms satisfactory outcome within the first year but longer-term results are not yet known. The histologic data obtained demonstrate that stent restenosis and occlusion are likely to be multifactorial, and challenge the assumption that myointimal hyperplasia is the sole cause of iliac stent occlusion.