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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Management ofIliac Stent
Thrombosis
89
History andPhysical Examination
A 58-year-old female underwent bilateral iliac
stenting in March 2006 by another vascular surgeon for symptoms of intermittent claudication
secondary to severe bilateral iliac artery occlusive disease. Medical comorbidities included
hypertension, hyperlipidemia, and nicotine abuse
(80 pack years). She had symptoms of left hip
pain on walking 50–60yards in December 2008.
Ankle brachial index (ABI) at rest was 1.08 on
the right and 0.82 on the left. With exercise testing, ABI decreased to 0.962 on the right and 0.56
on the left. She was found to have left common
iliac in-stent stenosis and underwent angioplasty
on January 5, 2009. However, thrombosis of the
stent developed 3 days following angioplasty.
Patient underwent repeat abdominal aortography
and study of the lower extremity on February 9,
2009, conrming left common and external iliac
artery occlusion and was offered aortofemoral
graft by the treating vascular surgeon (Fig.89.1).
Fig. 89.1 Abdominal aortogram and pelvic arteriogram showing occlusion of left iliac stent and left external iliac
artery thrombus
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_89
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400
89 Management ofIliac Stent Thrombosis
Patient came to our clinic on February 27, 2009,
and a noninvasive arterial Doppler study showed
an ABI of 1.01 on the right and 0.57 on the left.
Patient underwent repeat aortography which
showed thrombosis of the left CIA (stent) and
external iliac artery with large IMA.
Procedure
Thrombolysis of the left external iliac and common iliac artery via percutaneous puncture of the
left common femoral artery was started. An infusion catheter 10cm long was placed in the distal
abdominal aorta and common iliac stent and in
the left external iliac artery. A loading dose of
4mg TPA followed by 0.5mg/hour was continued for 24hours with near complete lysis of the
thrombus and establishing patency of the left
common iliac and external iliac artery (Fig.89.2).
Angioplasty of the previously placed left common iliac stent was performed using 8mm×4cm
OPTA®Pro balloon (Cordis, Hialeah, FL)
(Fig. 89.3). Another balloon-expandable left
common iliac stent extending to the external iliac
artery (8mm×3cm) was deployed (Fig.89.4).
Completion run showed less than 20% residual
stenosis (Fig. 89.5). Patient had satisfactory
result with relief of symptoms of intermittent
claudication and normal ABI (1 on both sides).
However, in 2011 patient developed symptoms of
recurrent claudication due to left common iliac
artery (CIA) in-stent stenosis (Fig. 89.6) for
which patient underwent left CIA angioplasty
with 8mm×4cm-long balloon with satisfactory
result (Fig. 89.7). Recurrent symptoms in 2014
necessitated repeat angioplasty for left CIA in- stent
Fig. 89.3 Partial lysis 23hours post lysis with TPA
Fig. 89.2 Abdominal aortogram via a left femoral sheath
Procedure
Fig. 89.4 Angioplasty of the previously placed left com-
mon iliac stent, and a new common iliac stent was
deployed 48hours following thrombolysis
401
Fig. 89.5 Patient left common iliac artery stent with
<20% stenosis, patent left external iliac artery
stenosis (70%). Following angioplasty there
was a residual stenosis of 10%. Patient did not
have any further symptoms of intermittent
claudication and her ABI in July 2017 showed
1.0 on the right and 1.0 on the left probably.
Patient died in June 2018 from squamous cell
carcinoma of the lung.
Fig. 89.6 Left common iliac in-stent stenosis
Fig. 89.7 Final result following angioplasty of in-stent
stenosis with <20% residual stenosis
402
89 Management ofIliac Stent Thrombosis
Discussion
After balloon angioplasty and deployment of
stent, inammatory response occurs in the host
artery leading to myointimal proliferation and
tissue ingrowth. Symptomatic iliac artery instent stenosis occurs with a frequency of 10%
at 1 year and may be more common at longterm follow- up and in patients with more complex lesions [1]. The treatment options include
standard balloon angioplasty, cutting balloon
angioplasty, or a placement of a covered stent.
In this patient thrombolysis with TPA became
necessary because of stent thrombosis. Iliac
stent restenosis and thrombus are caused by
a number of factors. Longer lesions, occlusions, diabetes mellitus, renal failure, and stent
undersizing are often implicated in the etiology
of stent thrombosis. Angioplasty for in-stent
stenosis may need to be repeated as was the
case in this patient two times following initial
thrombolysis.
Prior to the advent of balloon angioplasty and
stent technology, patients with TASC C and D
lesions were treated with aortofemoral grafting
which has excellent primary patency but signicant morbidity and mortality. We and others have
shown that iliac stenting as compared to aortofemoral grafting for TASC C and D lesions is
associated with shorter hospital stay, decreased
perioperative morbidity, decreased primary
patency, but similar secondary patency [2, 3].
References
1. Kudo T, Chandra FA, Ahn SS.Long-term outcomes
and predictors of iliac angioplasty with selective stenting. J Vasc Surg. 2005;42:466–75.
2. Hans SS, Desantis D, Siddiqui R, Khoury MD.Results
of endovascular therapy and aorto bifemoral grafting
for transatlantic inter-society types C and D aortoiliac
occlusive disease. Surgery. 2008;144:583–90.
3. Sachwani GR, Hans SS, Khoury MD, King TF, etal.
Results of iliac stenting and aortofemoral grafting for
iliac artery occlusion. J Vasc Surg. 2013;57(4):1030–7.
Iliac Stenting Complicated by Iliac Artery Rupture
90
Physical Examination andHistory
A 62-year-old male was seen in the outpatient
clinic with symptoms of intermittent claudication
affecting his left hip of 6 months duration on
walking 50–60yards in September 2006. Medical
comorbidities included hypertension, hyperlipidemia, and nicotine abuse (90 pack years). All the
pulses in the left lower extremity including the
femoral pulse were absent. Ankle brachial index
(ABI) on the right side was 1.0 and on the left
side was 0.69. Patient was taken to the interventional radiology suite for arteriography on
October 1, 2006. Aortography and study of the
lower extremities showed left common and left
external iliac artery occlusion with reconstitution
of common femoral artery just above the hip joint
(TASC D lesion) (Figs.90.1 and 90.2).
Procedure
Left femoral artery access was obtained percutaneously and a 6F sheath was placed. Using a
FRONTRUNNER® XP CTO catheter (Cordis,
Hialeah, FL), glidewire was advanced, and after
its passage in the subintimal plane, reentry was
obtained into the aortic lumen and conrmed
with contrast injection with the help of Kumpe
catheter (Cook Medical, Bloomington, IN). Two
self-expanding stents (smart 10mm×6cm) were
deployed following pre-angioplasty with a
6 mm × 10 cm-long balloon, and a postangioplasty was performed with an 8mm×6cmlong balloon at two sites. Completion run showed
patency of the left common iliac artery (CIA) and
external iliac artery, but there was evidence of
contrast extravasation in the proximal portion of
the left external iliac artery (Fig. 90.3). Patient
became hypotensive (systolic blood pressure
90mm hg with diaphoresis). Volume resuscitation with 500cc normal saline was started, heparin was reversed with protamine, and an
Fig. 90.1 Showing left common and external iliac artery
occlusion (TASC D)
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_90
403
404
Fig. 90.2 Reconstitution of the left common femoral
artery via collaterals
90 Iliac Stenting Complicated by Iliac Artery Rupture
Fig. 90.4 Prolonged balloon ination at low pressure for
control of bleeding following iliac rupture
Fig. 90.3 Contrast extravasation following iliac artery
angioplasty/stenting
8 mm × 6 cm-long balloon was inated to 4
atmospheric pressure for 10–15 minutes
(Fig.90.4). Patient responded well and his blood
pressure increased to 120/60 mm hg. Final run
showed no evidence of contrast extravasation
(Fig.90.5). Patient was last seen in October 2019,
13 years following left iliac intervention with
normal ABI (1.0) on both sides.
Fig. 90.5 Sealed perforation of the left external iliac
artery
Discussion
Iliac artery rupture during angioplasty/stenting and
EVAR is an under-reported complication. Allaire
etal. [1] reported an incidence of 0.8% of iliac rupture during angioplasty similar to that reported by
Palmaz etal. [2] of 0.9%. Iliac rupture is most often
associated with back pain, ank pain, and shock.
References
405
The major predictors of iliac artery rupture
during angioplasty are the presence of heavy
calcication in the plaque and oversizing the
post- angioplasty balloon. Optimal treatment
consists of immediate balloon tamponade and a
placement of a covered stent. In this patient, a
low- pressure prolonged balloon ination was
successful in tamponading the rupture. However,
the covered stent is a better option as delayed
rupture following immediate successful tamponade has been reported. Open surgical treatment often results in high morbidity and
mortality because of large hematoma over the
site of rupture and prior stenting of the ruptured
artery.
References
1. Allaire E, Melliere D, Poussier B, Kobeiter H, etal.
Iliac artery rupture during dilatation. Ann Vasc Surg.
2003;17(3):306–14.
2. Palmaz JC, Laborde JC, Rivera FJ, etal. Iliac artery rupture with a Palmaz stent: experience from a multicenter
trial. Cardiovasc Intervent Radiol. 1992;15:291–7.
Part XXV
Aorto-Iliac Stenting
Aortic Stenting forIsolated Aortic
Stenosis attheLevel oftheInferior
Mesenteric Artery
Physical Examination andHistory
A 78-year-old female was seen in the outpatient
clinic complaining of bilateral lower extremity
pain on walking 50–100 yards for the past
6months. The pain was worse in the right lower
extremity than in the left. She is a known patient
to hypertension and chronic obstructive pulmonary disease secondary to nicotine abuse. She
also has a history of coronary artery disease with
coronary stent placement in 2008 for unstable
angina. Examination of pulses of both lower
extremities revealed absent femoral, popliteal,
posterior tibial, and dorsalis pedis pulses on both
sides. Noninvasive Doppler arterial study showed
an ankle brachial index (ABI) of 0.75 on the right
and 0.76 on the left. She underwent CT angiography of the abdominal aorta and lower extremities
which showed near occlusion of the abdominal
aorta in close proximity to the origin of the inferior mesenteric artery (IMA, Fig.91.1).
Procedure
She was taken to the hybrid operating room on
March 23, 2017, and through a percutaneous
approach, a 5F sheath was inserted into the right
femoral artery and an Omniush marker catheter
(AngioDynamics, Latham, NY) and a
GLIDEWIRE® (Terumo, Tokyo, Japan) were
advanced into the suprarenal aorta. Abdominal
91
Fig. 91.1 CTA showing severe infrarenal aortic stenosis
with heavy calcication
aortogram showed near occlusion of the midsegment of infrarenal aorta (Fig.91.2). The 5F sheath
was exchanged for an 8F sheath and Glidewire
was exchanged for Amplatz Super Stiff™ (Boston
Scientic, Marlborough, MA) wire (0.038–260cm
long) which was passed into the thoracic aorta. A
VBX GORE®VIABAHN® Endoprosthesis
(W.L. Gore, Newark, DE) 11 × 59 mm covered
stent was deployed (Fig.91.3). A completion run
showed a dissection on the right side of the aorta at
the cephalad end of the stent. A second balloon
angioplasty was performed with a 12mm×4cm
balloon with resolution of the dissection and with
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_91
409
410
Fig. 91.2 Abdominal aortogram showing 80–90% trans-
verse diameter stenosis of the mid-infrarenal aortic
segment
91 Aortic Stenting forIsolated Aortic Stenosis attheLevel oftheInferior Mesenteric Artery
Fig. 91.4 Final result with <10% stenosis at the upper
end of the covered stent
<10% residual stenosis (Fig. 91.4). Patient had
palpable pulses in both feet, and bleeding was controlled with local pressure. She has been followed
for the past 2years and 9 months with a normal
Fig. 91.3 Post-angioplasty following deployment of the
covered stent
ABI on both sides, 1.0 on the right and 1.0 on the
left, on April 26, 2019, at her last visit.
Discussion
Focal stenosis of the infrarenal aorta is relatively
uncommon and occurs predominantly in young
women with history of heavy nicotine abuse,
hyperlipidemia, and premature ovarian failure.
Aortic endarterectomy and aortic bypass grafting
have been traditional treatment options for these
lesions. The long-term results of open aortic
reconstruction show excellent patency; however,
open reconstructions are associated with