Blood Flow Velocity Prediction in Aorto-iliac Stent Grafts ...
AORTO-ILIAC INTERVENTIONS
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Transcript of AORTO-ILIAC INTERVENTIONS
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Aorto-iliac InterventionsLevent Oguzkurt, MD
Baskent University School of MedicineSection of Interventional Radiology
Adana, Turkey [email protected]
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Disclosure
I have the following potential conlict of interests to report
Consultant: BARD, Covidien
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Surgical treatment: Aortoiliac bypass
• Patency – 82-91% at 5 years– 76-80% at 10 years
• Mortality: 3-4% at 30 days• Complications up to 21%
TASC ll
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Type of obstructive lesions– Stenoses
• High technical success– Chronic occlusions
• Technical failures – Acute/chronic thrombosis
• Complications
Methods of treatment – PTA – Bare metal stents
– Self-expanding– Balloon-expanding
– Covered stents – Thrombectomy/thrombolysis
Objectives of endovascular treatment • High technical/clinical success• Low complications • High patency rates on short and long term
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OBSTRUCTIONS INVOLVING THE AORTA
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Aorto-iliac occlusion (TASC D) • 3%-8% of aortoiliac occlusive disease• Distal type/proximal (complete) type
• High technical failures • High complication rates • Requirement for thrombus removal• Low primary and secondary patency • 20 patients • Primary patency 66% @ 2 years
Yuan L, et al. J Vasc Surg 2014 59:663-8
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Isolated aortic stenosis (TASC B) Localized form (normal iliacs) Diffuse form
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Isolated aortic stenosis
De vries JPP, et al. J Vasc Surg 2004 39:427-34
• 69 patient • PTA with provisional stenting
(24 stent placement)• Technical success: 98%• No major complications• 5 year patency patency:
• Primary: 75%• Secondary patency: 96%
• PTA vs stent: No difference
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Aortic stenosis with or without iliac artery involvementAdana Baskent Experience
• 40 patients (80% men); mean age, 59 years• 38 stenoses, 2 occlusions (iliac)• 18 patients aortic stenoses alone (localized/diffuse)• Mostly direct stenting (32 patients)• Technical success: 100%• Complications: 6/40 (15%)• Follow up: 1-72 months (median 24 months)• Patency at 3 years: 100% for aortic stenosis alone• Long term mortality higher in isolated aortic lesions
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ILIAC ARTERY OBSTRUCTIONS
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10 year patency after iliac a. stent placement• 110 patients (mean age 57 years)• 126 iliac lesion – 66 stenoses (PTA with provisional stent) – 60 occlusions (direct stent placement)
• Walstents• Primary/secondary patency (stent group) – 66%/79% @ 5 years – 46%/55% @ 10 years
• Survival – 83% after 5 years– 64% after 10 years
Schürmann K et al. Radiology 2002;224:731-8
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Dutch iliac stent trial • RCT • 279 patients (mean age, 58 years)
– PTA with selective stenting 136 pts – Stent placement 143 pts
• Iliac stenosis or short (<5 cm) occlusion• PTA with selective stent placement group had better
improvement clinically• ABI, iliac patency, score for quality of life were similar• Patency at a follow up of 6.3 years (0.7-8.6 years)
– PTA with selective stent placement: 74%– Stent placement: 83%
• Stent+selective stent vs PTA alone: No difference Klein WEM, et al Radiology 2006 238:734-44
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Primary stenting (vs PTA with provisional stenting)
• Direct stenting 110 patient• PTA with provisional stenting 41 patients
• Reduced perioperative complications (2.7% vs 24%)• Higher clinical success for longer stenosis (TASC C-D)• Similar clinical success on long term • Patency at 5 years – Similar for short stenosis – Higher with primary stenting for long segment occlusions
AbuRahma AF, J Vasc Surg 2007 46:965-70
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STent versus AnGioplasty (STAG) • Multicenter RCT • Only technically successful cases were randomized• Patency: Presence of flow (at 1 and 2 years)• Planned recruitmen 144 patients• Trial halted after 118 patients
Goode SD, et al. Br J Surg 2013 100:1148-53
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STent versus AnGioplasty (STAG)
Goode SD, et al. Br J Surg 2013 100:1148-53
• Multicenter RCT • Only technically successful cases were randomized• Patency: Presence of flow (at 1 and 2 years)• Planned recruitmen 144 patients• Trial halted after 118 patients
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(COBEST trial)
• Multicenter RCT– Covered stents (n=83 iliacs)– Bare metal stents (n=85 iliacs)
• Longest follow up 18 months • Restenoses (CI: 0.15-0.82)
– 8 in covered stent group– 20 in BMS group
• Complete occlusion (CI: 0.07-1.09)
– 3 in covered stent group – 10 in BMS group
• Less re-intervention in the covered stent group
Bibombe P, et al. J Vasc Surg 2011 54:1561-70TASC C&D
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Extensive iliac artery occlusions • TASC C and D• 19 studies, 1329 patients• Technical success: 86%-100%• Clinical improvement: 83%-100%• Length of hospitalization: 1-4.8
days• 5 year patency (8 studies)
– Primary patency: 60%-86%– Secondary patency: 80%-98%
• Mortality: 0-6.7%– 0% mortality in 12 studies– 1.2%-6.7% in 7 studies
• Morbidity: 3%-45%
• Most common complications: – Access site hematoma– Distal embolization– Arterial dissection – Pseudoaneurysm– Iliac artery or aortic rupture
Jongkind V J et al. Vasc Surg 2010 52:1376-83
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Adana Baskent University experience• 127 chronic iliac a. occlusions in 118 patients• Direct stent placement in all• Technical success: 117/127 (92%)• Complications
– Major 22 pts (19%)– Minor 7 pts (6%)
• Mortality 1 patient• Primary patency at 5 years: 63%• Secondary patentcy at 5 years: 93%
Ozkan U, Oguzkurt L. Cardiovasc Interv Radiol 2010 33:18-24
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90%
50%
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Chronic iliac artery occlusions
127 iliac a. (2001-2008)
104 iliac a. (2008-2013)
P value
Number of patients 118 93
Technical success 92% 99% <0.01
Patency @3 years(primary/secondary)
63%/93% 60%/95% >0.05
ComplicationsMajorMinor
24%19%6%
15%9%6%
<0.01
*Published data Unpublished data
Influence of increased experience
*Ozkan U, Oguzkurt L. Cardiovasc Interv Radiol 2010 33:18-24
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ENDOVASCULAR vs BYPASS
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Open bypass Endovascular P
No of patients 3733 1625
Hospital stay (mean, days) 13 4 <0.001
Complications 18% 13% <0.001
30-day mortality 2.6% 0.7% <0.001
Primary patency @5 years 94.8% 80% <0.001
Secondary patency@5 years 95.7% 90% <0.001
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RESTENOSIS
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Risk factors for aortoiliac PTA/stent restenosis
• Occlusion length • Number of stents placed (occlusion length)• Small-diameter artery • Younger age (small artery?)• CLI (vs claudication)• Poor distal runoff• Stent in the external iliac artery • Female gender (small artery?)• Comorbidities (DM or chr. renal insufficiency)
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• 102 recurrence out of 937 patients• Recurrent procedures:
– Higher morbidity during intervention – Lower clinical success– Lower 5-10 years patency
• Primary/secondary patency @ 10 years • 73%/90% (index procedure) • 66%/78% (recurrent procedure)
Davies MG, et al J Endovasc Ther 2011 18:169-180
Primary patency Secondary patency
• 84 iliac in-stent stenosis (BMS) – 61 stenoses– 23 occlusions
• Primary/secondary patency @ 5 years 38%/63%
Kropman RHJ et al EJVES, 2006; 32:634-8
PTA/stent for iliac in-stent restenosis
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Cutting balloon for ISR• 14 patients • 9 focal, 4 diffuse, 1 extended outside the stent
margin • Patency 100% (mean follow up of 24 months)
with CDUS
Tsetis D, et al. J Endovasc Ther 2008 15(2):193-202
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Direct stenting
• Reduced risk of rupture• Reduced distal embolism• Reduced overall
complications • Higher short term patency
PTA with provisional stenting
• Low short-term patency • Low/Similar long-term
patency • High complication • Nothing left behind
Direct stent placement recommended: – Aortoiliac junction (esp. balloon-expanding)– Heavy calcification (esp. balloon-expanding) – Iliac occlusions
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Endovascular treatment of aortoiliac disease…..• High rate of technical success • Low morbidity, low mortality • Success has been limited by – Technical failures (occlusions) – Acute stent thrombosis (infrequent)– Restenosis on short and long term
• Stents/covered stents have higher short-term success• Drug-eluting balloons/stents are waited
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Thank you…
Adana, Türkiye