4/18/2013 UC UC SF SF Disclosures Endovascular Approaches for • None TASC C/D Aorto-iliac Lesions: Endovascular First Approach? Jade S. Hiramoto, MD, MAS UCSF Vascular Symposium April 18, 2013 VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF TASC C Aorto-iliac Disease TASC D Aorto-iliac Disease • Surgery is preferred treatment for good-risk patient with type C lesion • Surgery is treatment of choice for type D lesion • Need to consider patient’s co-morbidities and operator’s success rate when making treatment recommendations VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 1
4/18/2013 UC UC SF SF Endovascular First: Endovascular Treatment: TASC C/D Aortoiliac Disease TASC C/D Lesions • High technical success rate with modest morbidity • Access: - Newer available technologies - Ipsilateral retrograde - Increased experience and skill set: results should get - Contralateral crossover even better - Bilateral femoral - Brachial access - Combined femoral/brachial approach • Re-interventions can be performed percutaneously - Hybrid approach: open femoral endarterectomy - Secondary patency rates comparable to open surgery • Crossing techniques: • Still candidate for conventional surgical therapy - Subintimal angioplasty - If outcome does not meet expectations, not much lost - Re-entry devices - CTO devices VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Chronic Left Common Iliac Artery Occlusion Potential Complications • Vessel wall perforation • Dissection • Avulsion of vessel from aorta • Embolization • Access site complications VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 2
4/18/2013 UC UC SF SF Chronic Left Common Iliac Artery Occlusion Chronic Left Common Iliac Artery Occlusion •Unable to cross from right femoral approach •Left femoral access •Kumpe catheter/glide wire, subintimal plane •Multiple unsuccessful attempts to re-enter true lumen in aorta •Re-entry device VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Chronic Left Common Iliac Artery Occlusion •Balloon-expandable kissing stents •Additional self- expandable stent into L CIA VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 3
4/18/2013 UC UC SF SF •Left brachial access •Combined left brachial and right femoral access: unable to re-enter •Unsuccessful attempts at re-entry true lumen •Re-entry catheter used from right VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO femoral access UC UC SF SF •Kissing I-cast covered stents •Rupture of distal R CIA •Wallstent into R external iliac artery VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 4
4/18/2013 UC UC Systematic Review SF SF Endovascular First for Treatment of TASC C/D Lesion • Not a question of can we do it, but should we do it? • 19 nonrandomized studies with 1711 patients; 1329 with extensive AIOD • All single center results , all retrospective, varied patient selection VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO Jongkind et al; JVS 2010 Systematic Review UC UC Systematic Review SF SF • Technical success reported in all studies: range 86% to 100% • No perioperative or 30-day mortality in 12 studies • Reasons for technical failure: inability to cross occluded segment, thrombosis • 7 studies reported mortality rate ranging from 1.2%-6.7% after recanalization, iliac artery rupture VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO Jongkind et al; JVS 2010 Jongkind et al; JVS 2010 5
4/18/2013 UC UC SF Systematic Review SF Meta-Analysis of Endovascular Treatment of TASC C/D Lesions • Sixteen articles: 958 patients with TASC C and D AIOD treated with endovascular therapy - Minimum of 10 cases/study - Procedural details - Immediate technical success - Primary patency - Included cases with primary as well as selective stenting - 8/16 studies included in previous systematic review • Pooled estimate for technical success: - 92.8% (89.8%-95.0%) • Primary patency at 12 months: • 4- or 5-year primary patency rates: 60%-86% • 1-year primary patency rates: 70%-97% - 88.7% (85.9%-91.0%) • 4- or 5-year secondary patency rates: 80-98% • 1-year secondary patency rates: 88-100% VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO Ye et al; JVS 2011 Jongkind et al; JVS 2010 UC UC SF SF Meta-Analysis of Endovascular Meta-Analysis of Endovascular treatment of TASC C/D Lesions Treatment of TASC C/D Lesions VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO Ye et al; JVS 2011 Ye et al; JVS 2011 6
4/18/2013 UC UC SF SF Endovascular Treatment of Extensive AIOD: Endovascular Treatment of Extensive AIOD: Single Center Experience of 1712 Single Center Experience of 1712 Interventions Interventions • 1712 procedures in 1184 patients to treat lesions • 1337 interventions in iliac arteries; 292 involved aortic in distal aorta and iliac arteries: 9/1996-12/2006 bifurcation, 83 in distal aorta/bifurcation • 30 day mortality was 1.1%; mean F/U 3.24 years • Primary endpoint: - 1-year duplex-based primary patency • 12 and 24-month restenosis, TLR, and primary/secondary patency rates did not differ among TASC II A-D subgroups • Secondary endpoints: - Technical success • Outcomes for complex interventions in distal aorta or aortic - Secondary patency bifurcation did not differ compared to total cohort - TLR VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO Sixt et al; JEVT 2013 Sixt et al; JEVT 2013 UC UC Endovascular Treatment of Extensive AIOD: SF SF Single Center Experience of 1712 Covered vs Bare Balloon Expandable Stents Interventions • Benefit of covered stents: - Reduce intimal hyperplasia - Less thrombogenic than BMS? • Freedom from restenosis, amputation, or surgery: better • Numerous reports demonstrate promising results in TASC A+B compared to • One randomized trial: Covered Versus Balloon TASC C+D Expandable Stent Trial (COBEST) - 168 iliac arteries in 125 patients with TASC B/C/D lesions - Randomly assigned to receive Advanta V12 covered stent (Atrium) or commercially available bare metal balloon expandable stents - Follow-up at 1, 6, 12, and 18 months VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO Sixt et al; JEVT 2013 7
4/18/2013 UC UC SF SF COBEST: COBEST: Primary Outcomes Freedom From Binary Restenosis* TASC C/D group TASC B group *More TASC D lesions in covered stent group Freedom from binary restenosis Freedom from stent occlusion VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO Mwipatayi et al; JVS 2011 Mwipatayi et al; JVS 2011 UC UC SF SF Comparison of Techniques for DISCOVER Trial Extensive AIOD • Dutch Iliac Stent Trial: COVERed balloon-expandable versus uncovered balloon-expandable stents in the Open surgery Endovascular Repair common iliac artery • Higher mortality • Lower mortality - Prospective, randomized, double-blind, multi-center trial - Symptomatic atherosclerotic disease of the CIA, defined as • Higher morbidity, more • Lower morbidity, less stenoses>3 cm and occlusions significant significant - Randomized to Advanta V12 PTFE-covered stent or a • Better primary patency • Lower primary patency balloon-expandable uncovered stent • Equal secondary patency • Equal secondary patency • Increased length of stay • Decreased length of stay • Primary endpoint: • Limited by physiology • Limited by anatomy - Absence of binary restenosis rate • Sexual dysfunction, return to • Secondary endpoints: normal activity - Re-occlusion rate, TLR, clinical/procedural/hemodynamic success, major amputation, complication, mortality VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 8
4/18/2013 UC UC SF SF Conclusions Endovascular Treatment of TASC C/D AIOD • Endovascular first approach TASC C/D: • Most (>90%) TASC C/D lesions can be successfully treated - High operator success rate - Significant patient co-morbidities - Depends on how hard you want to work • Liberal use of covered stents, especially difficult • Open surgery first approach TASC C/D: cases, long segment occlusions - Less experienced with complex endovascular techniques - Good risk, young patient • Be prepared for complications, usually rupture - Juxtarenal aortic occlusion or dissection • Long term patency may improve with regular use of covered stents VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 9
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