Andrew Bunney MD, PGY-4
University of Minnesota
bunne035@umn.edu
Chief Complaint and HPI
• CC: Pulseless RLE
• HPI: 46 year old male with a history of severe
atherosclerotic disease which had required multiple
procedures, including bilateral iliac artery stent
placement. The patient has been noncompliant with
medications, including anticoagulation, for the past
4 months. Presented with sharp RLE pain. PE
found a pulseless RLE.
PMH, PSH, Drugs, Allergies
• PMH: DM type 2, COPD, Depression, CAD with MI,
HTN, HLP, severe PAD
• PSH: Multiple bi-iliac interventions with angioplasty
and stenting 2-3 years prior to presentation.
• Social History: Smoking 1ppd, ETOH
• Medications: ASA 325mg, Insulin 70U/day,
Lisinopril 10mg, Gemfibrozil 600mg BID
• Allergies: Plavix
Noninvasive Imaging
Oblique MIP
image of CTA
demonstrating
occluded distal
aorta and R
CIA stent. R
EIA partially
patent but
occluded
distally with
patent R CFA.
Oblique MIP
image of CTA
demonstrating
occluded distal
aorta and L CIA
stent. L EIA
and L CFA
appear patent
with long
stenosis of L
EIA.
Noninvasive Imaging
Diagnosis and Discussion
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Diagnosis: Acute Aortobi-iliac occlusion with critical
RLE ischemia manifested by rest pain (Fontaine
stage III or Rutherford grade II).
Treatment choice in aortoiliac disease depends on
complexity of lesion. Can use the TransAtlantic
InterSociety Consensus (TASC II) criteria,
established in 2007.
– Type A and B lesions treatment of choice with
endovascular therapy
– Type C and D lesions treatment of choice with
surgery
This lesion is a type D lesion, primary treatment is
generally considered to be open surgery.
Given the severe occlusive disease on CTA and high
perioperative cardiac risk (calculated at 11%), the
patient was considered not to be a good surgical
candidate for reconstruction. Interventional radiology
was consulted to attempt endovascular
revascularization.
TASC Type A
TASC Type B
TASC Type C
TASC Type D
Possible Complications
• A major complication is defined by any complication that
results in additional therapy or prolonged hospitalization.
– 4.3% for iliac PTA and 5.2% for iliac stenting.
– 30-day mortality rate of 1% for iliac PTA and 0.8% for iliac stenting.
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Arterial rupture (0.8-0.9%)
Distal Embolization
Stent Infections
Arterioureteric fistula after iliac stenting – one reported case
Dissections
Access site pseudoanuerysm or hematoma
Intervention
• Right CFA access was
obtained. Occlusion was
crossed and an aortogram
obtained.
• Left CFA access obtained
and occlusion crossed.
• Thrombolytics started at
0.5mg/hr through both
sheaths.
• Post thrombolytics
angiogram showed
recanalization of the
occlusion.
Intervention
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Multifocal stenoses visualized in aorta and
common iliacs. Opted for further treatment with
aortic stenting and extension of previous bi-iliac
stents using a chimney technique.
A 4cm long 14mm diameter self expanding stent
was deployed from the right CFA access 2cm
inferior to the renal arteries.
Stent was post-dilated with 10 and 12 mm balloons.
Wire access from the left CFA was adjusted from
an extraluminal to intraluminal position so both
CFA accesses have continuity with the true
lumen of the aorta.
Next, a 8mm x 10cm long Viabahn covered selfexpanding stent was placed from the aorta to the
L CIA and a 8mm x 15cm long Viabahn covered
self-expanding stent placed from the aorta to the
R CIA simultaneously.
Both stents post-dilated with 6mm balloons
using a kissing technique.
Residual stenosis was seen in the proximal L
EIA (not pictured). A 8mm x 8cm self-expanding
stent was placed just distal to the patent L
inferior epigastric artery and post-dilated with a
6mm balloon.
Final angiogram demonstrates technical success
with patent aortobi-iliac flow. Focal dissection at
distal L CIA near hypogastric takeoff treated with
PTA.
Intervention
• Followup CTA
performed 5 months
after intervention
shows patent stents
with focal stenosis
between the L CIA
and L EIA stents.
• This was
successfully
angioplastied in a
followup procedure.
Summary
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TASC C and D lesions, although traditionally treated surgically, can be successfully
managed with an endovascular approach with comparable patency rates.
Intervention
5 year patency
10 year patency
Endovascular Iliac Stent
70-93% (92-95% 2ndary)
65-68% (87% 2ndary)
Aortobi-iliac Surgical bypass graft
90%
75%
Ax-unifemoral
44-79%
Ax-bifem
50-76%
Fem-fem
55-92%
One recent study states that outcomes of aortic or aortic bifurcation interventions had no
significant difference in outcomes from iliac interventions for TASC C and D lesions.
– Study of 292 aortic bifurcation lesions and 83 distal aorta/bifurcation lesions compared
to 1337 iliac lesions.
Current guidelines recommend antiplatelet therapy with ASA or clopidogrel at the time of
endovascular intervention and continuation indefinitely to help prevent stent thrombus.
Surveillance varies. Our institution follows our patients in clinic at 3, 6 and 12 months after
intervention and then annually. Ultrasound or other imaging is done on a clinical basis.
References
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Nieson M. Endovascular Management of Aortoiliac Occlusive Disease. Seminars in Interventional
Radiology 2009;26(4):296-302.
Ahn S, Murphy T. Aortoiliac Angioplasty and Stents. Handbook of Interventional Radiologic Procedures.
Lipincott Williams and Wilkins, New York 2011.
Norgren L et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).
Journal of Vascular Surgery 2007;45:S5-67.
Yin M et al. Endovascular Interventions for TransAtlantic InterSociety Consensus II C and D
Femoropopliteal lesions. Chin Med J 2013;126:415-420.
Baril DT et al . Endovascular interventions for TASC II D femoropopliteal lesions. J Vasc Surg 2010; 51:
1406-1412.
Piazza M et al. Iliac artery stenting combined with open femoral endarterectomy is as effective as open
surgical reconstruction for severe iliac and common femoral occlusive disease. J Vasc Surgery
2011;54(2):402-411.
Balzer J O et al. Percutaneous interventional reconstruction of the iliac arteries: primary and long-term
success rate in selected TASC C and D lesions. Eur Radiol.2006;16:124–131.
Leville C D et al. Endovascular management of iliac artery occlusions: extending treatment to
TransAtlantic Inter-Society Consensus class C and D patients. J Vasc Surg. 2006;43:32–39.
Sixt S et al. Acute and long-term outcome of endovascular therapy for aortoiliac occlusive lesions
stratified according to the TASC classification: a single-center experience. J Endovasc
Ther. 2008;15:408–416.
Sixt S et al. Endovascular Treatment for Extensive Aortoiliac Artery Reconstruction: A Single-Center
Experience based on 1712 Interventions. J Endovasc Ther 2013;20(1):64-73.
Questions?
• bunne035@umn.edu