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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Iliac Stenting forChronic Total
Occlusion Using Brachial Artery
Access
86
History
A 45-year-old male was referred by his interventional cardiologist for aortofemoral grafting.
Patient complained of signicant pain in the right
hip on walking 50 yards. Patient was diagnosed
with right common iliac artery occlusion in
August 2009.
Procedure
In June 2009, patient had emergency coronary
artery bypass graft for a recent myocardial infarction with triple vessel disease. He had placement
of intra-aortic balloon catheter insertion for cardiogenic shock prior to coronary artery bypass
graft. Intra-aortic balloon pump was inserted percutaneously via left femoral artery. At that time, a
left common iliac artery stent was deployed by
the interventionalist cardiologist because of the
presence of severe left common iliac artery stenosis. Patient had emergency coronary artery
bypass graft using internal mammary artery as an
arterial conduit, greater saphenous vein, and left
radial artery.
Review of the lms from the cardiac cath laboratory revealed total occlusion of the right common iliac artery with a very short stump and with
a reconstitution of external iliac artery (small
diameter). Left common iliac artery stent was patent but extended for a distance of 2.5cm above
the aortic bifurcation. Patient underwent percutaneous right iliac intervention via puncture of the
left femoral artery, and an abdominal aortogram
and pelvic arteriogram were obtained (Fig.86.1).
The right femoral artery was punctured, and a 5F
sheath was inserted. Glidewire was advanced, and
using a Kumpe catheter (Cook Medical,
Bloomington, IN) subintimal dissection was performed, but wire could not enter the true lumen of
the distal abdominal aorta or the proximal common iliac artery in spite of repeated attempts. Left
brachial artery was punctured percutaneously
Fig. 86.1 Aortogram via left femoral artery access show-
ing right common iliac artery occlusion
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_86
387
388
86 Iliac Stenting forChronic Total Occlusion Using Brachial Artery Access
Fig. 86.3 Guidewire crossing the right external iliac
artery post-stent angioplasty of right common iliac stent
extending into distal aorta and kissing balloon in the left
common iliac stent
Fig. 86.2 Catheter aortogram via left brachial approach
showing previously placed left common iliac stent extending into the distal abdominal aorta
under local anesthesia with micropuncture technique. A 5F sheath was inserted in the left brachial artery. An exchange length angle stiff
glidewire 260 cm 035 long was advanced and
using a 125cm 5F vertebral catheter which was
advanced into the distal aorta. The catheter was
negotiated with the help of the glidewire behind
the previously placed stent into the right common
iliac artery, and we were able to advance the wire
with the support from vertebral catheter into the
common femoral artery (Fig.86.2). 5F sheath in
the brachial artery was exchanged for 6F 90cm
long arrow sheath (BRITE TIP®, Cordis, Hialeah,
FL). Following heparinization, pre-angioplasty of
the right common iliac artery was performed with
a 5×4cm balloon followed by 6×4cm balloon.
Another kissing balloon 6×4 was placed in the
left common iliac stent and the native common
iliac artery. Both balloons were simultaneously
inated to 8 atmospheric pressures, and an
8mm×10cm long self- expanding EV3 Protégé
stent (Covidien, Plymouth, MN) was deployed
just inferior to the previously placed stent in the
Fig. 86.4 Abdominal and pelvic aortogram showing suc-
cessful aortoiliac stenting
distal abdominal aorta in the common iliac artery
(Fig. 86.3). A post-angioplasty was performed
with a 7×4cm OPTA®Pro balloon (Cordis), and
the left common iliac balloon was kept inated
during that time. Completion run showed excellent technical result (Fig.86.4). Patient was lost to
follow-up after 5years, and during the last followup in September 2014, his ankle brachial index
was one on each side.
References
389
Discussion
Endovascular management of iliac artery occlusion (TASC II C and D lesions) can sometimes
be a technically challenging procedure.
Diagnosis of concomitant aortic or common
femoral artery disease is important to determine
the type of approach to be used for arterial
access. Arterial access can be obtained via an
ipsilateral retrograde versus a contralateral transfemoral or transbrachial approach [1]. As there is
minimal support from the catheter from the contralateral femoral approach, ipsilateral retrograde approach is generally preferred. Left
transbrachial access using a balloon occlusion of
the contralateral patent iliac artery is favored by
Bechara etal. [2]. In this patient, left transbrachial access was selected as we could not
advance the guidewire into the true lumen from
the subadventitial dissection plane from the right
retrograde approach. Percutaneous brachial
access is preferred when using 6 F sheath, but
open brachial artery exposure is better when a
7F or larger sheath becomes necessary. Kissing
balloons and stents are typically used for lesions
at the aortic bifurcation even with a unilateral
lesion because of concerns for contralateral
common iliac artery compression, plaque dislodgement with subsequent embolization, or
dissection.
References
1. Kim H, Harth K, Kashyap VS. Endovascular management of aortoiliac occlusive disease. In: Hans SS,
Shephard AD, Weaver MR, Bove PG, Long GW, editors. Endovascular and open vascular reconstruction:
a practical approach. Boca Raton: CRC Press; 2018.
p.27–34.
2. Bechara CF, Barshes NR, Lin PH, Kougias
P. Recanalization of ush iliac occlusions with the
assistance of a contralateral iliac occlusive balloon. J
Vasc Surg. 2012;55:872–4.
Covered Stent Placement forFlush
Occlusion ofCommon Iliac Artery:
A12-Year Follow-Up
87
Physical Examination andHistory
A 60-year-old male was seen in the outpatient
clinic with symptoms of right hip claudication on
walking 40–50 yards in January 2008. Medical
comorbidities included hypertension, coronary
artery disease (history of debrillator and pacemaker), and chronic obstructive pulmonary disease (nicotine abuse, 80 pack years). Right
femoral pulse was absent, and no pulses were
palpable in the right lower extremity below that
level. Ankle brachial index on the right side was
0.6 and on the left 0.8.
Procedure
Patient was taken to the interventional radiology
suite where percutaneous access was obtained in
the left common femoral artery by micropuncture
technique and a 5 F sheath was advanced in
abdominal aortogram, and pelvic arteriogram was
obtained with the help of Omniush catheter
(AngioDynamics, Latham, NY) through a 5 F
sheath. Abdominal aortogram showed ush occlusion of the right common iliac artery with heavy
calcication with reconstitution of distal CIA
near its bifurcation (Figs. 87.1 and 87.2). The
right femoral artery was punctured percutaneously by road mapping technique and 5F sheath
was inserted. Using Kumpe catheter (Cook
Medical, Bloomington, IN) and a glidewire, right
common iliac artery occlusion was crossed. A
pre-angioplasty was performed with a
6mm×4cm OPTA®Pro balloon (Cordis, Hialeah,
FL). Since the lesion was calcied, it was decided
to deploy covered stent (8 mm × 4 cm long)
through a 9F sheath in the right common femoral
artery. Another self-expanding (8 mm × 6 cm)
S.M.A.R.T. CONTROL stent was deployed with
an overlap of covered stent for about 5mm. Postangioplasty was performed using 8mm ×6 cm
OPTA®Pro balloon. Completion run showed satisfactory result, but there was occlusion of the
right hypogastric artery (Fig.87.3). In December
Fig. 87.1 Showing “ush” occlusion of the right com-
mon iliac artery
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_87
391
392
Fig. 87.2 Stenosis of the distal common iliac artery
beyond the occluded segment
87 Covered Stent Placement forFlush Occlusion ofCommon Iliac Artery: A12-Year Follow-Up
the right foot with monophasic wave forms with
unrecordable ankle brachial index. CT angiography showed occlusion of the right distal external
iliac, common femoral, and deep femoral artery
with reconstitution of popliteal artery. Patient
underwent emergent thrombectomy of the distal
external iliac, common femoral, and deep femoral artery through a hockey stick incision in the
right groin. Arteriography via 7F sheath in the
right femoral artery was performed. There was
evidence of chronic right supercial femoral
artery occlusion. Right common femoral and
deep femoral endarterectomy with bovine
pericardial patch was performed, and thrombectomy of the distal external iliac artery with
Fogarty® balloon catheter (Edwards, Irvine, CA)
was performed. Patient was last seen in October
2019 with an ankle brachial index of 0.76 on the
right and 1.0 on the left. Patient underwent right
axillary to brachial artery in situ bypass using
basilic vein for long segment occlusion of the
right brachial artery (embolic occlusion) as
patient presented to the outpatient clinic 3 weeks
following the onset of symptoms. The upper
extremity in situ bypass has remained patent for
the past 1year.
Fig. 87.3 Placement of covered stent in the right com-
mon iliac artery without visualization of the right hypogastric artery (occlusion)
2014, patient underwent left femoral posterior
tibial in situ bypass following a failed left supercial femoral artery stenting. In August 2018,
patient presented with the giving out of his right
lower extremity. Doppler evaluation of the lower
extremities revealed markedly diminished ow in
Discussion
Sachwani et al. reviewed results of 103 percutaneous interventions (iliac stenting) in 100
patients and compared with results of aortofemoral grafting performed in 101 patients
and observed that iliac stenting for iliac artery
occlusions has lower morbidity, shorter hospital
length of stay, and equivalent secondary patency,
and inferior primary patency compared with aortofemoral graftings [1].
During the last decade, the data has continued
to accumulate to support the use of stent grafts in
the long segment iliac artery occlusions. In
patients with occlusion of the iliac arteries with
calcication, use of bare-metal balloonexpandable stents may result in perforation during post-angioplasty, particularly in patients with
References
393
oversized stents. Piazza etal. reported results of
self-expanding PTFE-covered stents versus
bare- metal stents for chronic iliac artery occlusions and reported higher midterm patency rates
for covered stents as compared to bare-metal
stents. The use of covered stents is preferable if
occlusion of common iliac artery is longer than
3.5cm and calcication involves 70% or more of
the arterial circumference [2].
References
1. Sachwani GR, Hans SS, Khoury MD, King TF.Results
of iliac stenting and aortofemoral grafting for iliac
artery occlusions. J Vasc Surg. 2013;57(4):1030–7.
2. Piazza M, Squizzato F, Dall’Antonia A, Lepidi
S. Outcomes of self-expanding PTFE covered stent
verses bare metal stents for chronic iliac artery occlusion in matched cohorts using propensity score modeling. Eur J Vasc Endovasc Surg. 2017;54:175–85.
Covered Iliac Stenting for
Acute onChronic Ischemia
Following Thoracotomy
88
History andPhysical Examination
A 66-year-old male underwent thoracotomy and
right upper lobectomy for carcinoma of the lung
on November 25, 2015. Medical comorbidities
included chronic obstructive pulmonary disease
secondary to nicotine abuse (80 pack years), coronary artery disease with a remote coronary
artery bypass graft, and carotid endarterectomy
(CEA). There was no Doppler ow (posterior
tibial or dorsalis pedis) in the right lower extremity. Ankle brachial index (ABI) on the left side
was 0.6. Emergent CTA of the abdominal aorta
and runoff study showed infrarenal aortic ectasia
with small amount of mural thrombus. There was
occlusion of the right common iliac artery (CIA)
with associated stenosis of the right external iliac
artery and lling defect likely due to thrombus.
There was evidence of distal left CIA stenosis as
well as moderate stenosis of the left external iliac
artery (Fig.88.1).
Procedure
Right femoral artery cutdown was performed
and 5F sheaths were inserted. The left femoral
artery was punctured percutaneously with a
micropuncture technique, and a 5F sheath was
advanced. Attempt to pass the glidewire from
the left side into the abdominal aorta resulted in
the wire being in a subintimal plane. On the
right side a Glidewire was advanced and an
Omniush catheter (AngioDynamics, Latham,
NY) was placed in the abdominal aorta and an
abdominal and pelvic aortogram was obtained
(Fig.88.2). With the help of Omniush catheter
placed at the aortic bifurcation, left CIA was
selected, and an angle stiff glidewire (180cm–
035) was advanced into the common femoral
artery (Fig. 88.3). A 9 mm× 8 cm-long selfexpanding stent (Smart-Cordis) was deployed
in the left external iliac artery with a 5 mm
overlap of a balloon-expandable 8mm×4 cm
Omnilink stent (Abbott, Abbott Park, IL) in the
left CIA (Fig.88.4). On the right side, the 6F
sheath was replaced by a 11F sheath, and a
10 mm × 5 cm-long GORE
Endoprosthesis (W.L. Gore, Newark, DE) was
deployed in the right CIA and an 8 × 5 cm
®
GORE
placed in the right external iliac artery. Postangioplasty was performed with a 10mm×5cm
OPTA®Pro balloon (Cordis, Hialeah, FL) in the
right CIA stent and an 8mm×5cm OPTA®Pro
balloon in the right external iliac stent
(Figs. 88.5 and 88.6). The sheaths and wires
were removed; the right femoral endarterectomy with bovine patch was performed with
closure of the right groin in layers. Patient was
last seen in October 2019 with an ABI on the
right and left of 1.0.
VIABAHN® Endoprosthesis graft was
®
VIABAHN®
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_88
395
396
Fig. 88.1 CTA abdomen and pelvis showing distal aortic ectasia with laminated thrombus and right common and
proximal external iliac artery occlusion with stenosis of the left common iliac and left external iliac artery
88 Covered Iliac Stenting forAcute onChronic Ischemia Following Thoracotomy
Fig. 88.2 Aortogram showing thrombus in the right CIA
and external iliac artery with stenosis of distal common
iliac and proximal external iliac artery
Fig. 88.3 A crossover Pinnacle sheath in the left CIA and
guidewire in the left common femoral artery
Discussion
397
Fig. 88.4 Deployed stents in the left CIA and external
iliac artery and deployment of right CIA covered stent
Fig. 88.5 Post-angioplasty of right common iliac stent
and right external iliac artery covered stent
Discussion
This case illustrates the use of hybrid approach
for management of common and external iliac
artery thrombosis resulting in acute ischemia
with concomitant femoral endarterectomy. Chang
etal. reported 171 patients who underwent common femoral artery endarterectomies and iliac
Fig. 88.6 Completion run showing patency of right CIA
and right external iliac artery with non-lling of the right
hypogastric artery
stent/stent grafting from 1997 to 2006 with 46%
presenting with symptoms of intermittent claudication and the remaining with tissue loss and rest
pain [1]. They deployed stent graft in 41% of
their patients. Their technical success was 98%
with primary patency (60%), primary assisted
patency 97%, and secondary patency 98%. Use
of stent grafts compared with bare-metal stents
was associated with signicant higher patency by
logistic regression analysis (87% ± 5% vs
53%±7%, p<0.01) [1]. Covered stents are pref-
erable in patients with CIA occlusions with
eccentric plaques containing large amount of calcium that are at a high risk of rupture during poststent angioplasty with bare-metal stents. During
deployment of covered stents, meticulous calculation of the stent length should be taken into
consideration to avoid inadvertent coverage of
the hypogastric artery [2]. In this patient the right
hypogastric artery was stenotic at its origin, and
coverage of the hypogastric artery did not result
in pelvic ischemia. In patients with chronic arterial occlusive disease, acute ischemia may occur
secondary to hypotension from volume decit.
Hydration and optimization of the cardiac status
(if possible) should proceed simultaneously as
the intervention for acute on chronic ischemia is
being undertaken.
398
88 Covered Iliac Stenting forAcute onChronic Ischemia Following Thoracotomy
References
1. Chang RW, Goodney PP, Beak JH, Nolan BW, etal.
Long-term results of common femoral endarterectomy
and iliac stenting/stent grafting for occlusive disease. J
Vasc Surg. 2008;48(2):362–7.
2. Kim H, Harth K, Kashyap VS.Endovascular management of aortoiliac occlusions. In: Hans SS, Shephard
AD, Weaver MR, Bove PG, Long GW, editors.
Endovascular and open vascular reconstruction: a
practical approach. Boca Raton: CRC Press; 2018.
p.27–34.