4/18/2015 Role of endovascular therapy in TASC II C & D inflow disease Per the TASC II Document: • Surgery is the treatment of choice for type D lesions • Surgery is the preferred treatment for good-risk patients with type C lesions. The patient's co-morbidities, fully informed patient preference and the Aortoiliac occlusive disease local operator's long-term success rates must be considered when making Bala Ramanan, MBBS treatment recommendations for type C 1 st year vascular surgery fellow lesions • Since the introduction of TASC guidelines for the treatment of aortoiliac occlusive disease, there has been tremendous advancement in endovascular techniques Data available since the TASC II guidelines were published Case Presentation • 63 year old female. • Life style limiting left calf claudication for one year. • CT angiogram at outside hospital demonstrated left diffuse common and external iliac disease. • Unsuccessful anterograde and retrograde attempts at an outside hospital 2 weeks prior to presentation at UCSF. • PMH: HTN, dyslipidemia, CAD s/p MI 2006 and subsequent PCI-stable from cardiac • Review articles and several studies have shown the feasibility of endovascular standpoint for surgery. therapy for TASC II C and D lesions. • Medications: Tylenol with codeine, alprazolam, aspirin, carvedilol, metformin, • Primary patency rate is lower for endovascular therapy compared to surgery (60- multivitamin, simvastatin . 86%) at 5 years. • SH: 99 pack-year smoking history, stopped 2 months prior to presentation, non- • Secondary patency rate is 80-98% for endovascular therapy at 5 years. drinker. 1
4/18/2015 Physical Examination Imaging: CT angiogram • Abdomen- soft, non tender. Aorta not palpable. • Left groin incision was not completely healed. No sign of infection. • Pulse exam: R side lower extremity pulses were normal. • Left lower extremity pulses were not palpable. • Left foot was cool with intact capillary refill, some digit mottling and dependent rubor. No cyanosis or ulcerations. • Non invasive studies: ABI : Right-139 (0.87)/ Left-60 (0.56). • Toe Pressures : 89 (0.56)/ 43 (0.32). Small common iliac arteries with severe calcification on the left side Aortic bifurcation with severe calcification 2
4/18/2015 Patent profunda femoris arteries bilaterally Bilateral CFA calcification worse on the left Angiogram Outside Hospital L CFA shows severe calcification and stenosis 3
4/18/2015 What would you do? Case Management A. Aortobifemoral bypass with femoral artery endarterectomy. 38% B. Left iliac stent with L Common femoral • Bilateral common iliac balloon expandable covered stents endarterectomy. in a kissing technique, left external iliac artery self- C. Bilateral “kissing” common iliac stents expanding covered stent with left common femoral 17% 17% with L common femoral endarterectomy. 14% 14% D. Right iliac stent with right to left femoro- endarterectomy. femoral bypass and left CFA endarterectomy. E. As per CLEVER trial, supervised exercise, . . . . . . . . . . . w i o h e . p risk factor management and guideline- . m g s C . i u m r s s a L h o , p h t a l y c i t w i b i ” r directed medical optimization. w g t l t a n n R t i r n s e E o t V e s m t i s E k e s “ c L c a C f l i a a l i b i i r l r e o i e t p t t h t r f a g s o e l i A A L i R B POST DEPLOYMENT OF BALLOON EXPANDABLE KISSING STENTS PREINTERVENTION ANGIOGRAM 4
4/18/2015 POSTINTERVENTION ANGIOGRAM TO WHAT LEVEL SHOULD THE AORTIC BIFURCATION BE RAISED? 79% A. 1-2 cm above the native aortic bifurcation. B. 2-3 cm above the native aortic bifurcation. 21% C. aortic bifurcation should never be raised. 0% . . . . . . . . . d e e l u v v i i o t t a a h n n s e e n h h o t t i t e e a v v c r o o u b b f a a i b m m c i c c t r 2 3 o - - 1 2 a ISSUES AROUND RAISING THE AORTIC BIFURCATION WOULD YOU USE COVERED OR BARE METAL STENT IN • Greiner and colleagues showed that if the proximal end of the kissing stents THE COMMON ILIAC ARTERY? overlapped by more than half of the angiographic width within the aorta their 2 year primary and assisted primary patency rate was significantly 54% less than if the stents crossed by less than 50%. 46% A. Covered stent. • Compression phenomenon can occur B. Bare metal stent. with kissing stent technique- one of the kissing stents compresses the other one and diminishes the lumen until unilateral occlusion follows. Diagnosed on CT scan. • Ability to cross from one femoral artery . . t t n n e e to another may be eliminated. t t s s d l a e r t e e m v o e C r a B 5
4/18/2015 • COBEST RCT. • N= 168 iliac arteries in 125 patients with severe aortoiliac occlusive disease. • RESULTS: • Covered stent was associated with less binary restenosis. • Covered stent was associated with higher freedom from occlusion than bare metal stent (but did not reach statistical significance). • TASC C and D lesions treated with covered stents had less binary restenosis than those treated with bare metal stents. 6
Recommend
More recommend
