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References
411
signicant mortality and morbidity. Moreover, in
male patients, open aortic reconstruction may
lead to retrograde ejaculation. During the last
three decades, percutaneous angioplasty has been
increasingly used to treat focal stenosis of the
abdominal aorta with satisfactory short-term and
long-term results. Simons et al. (1998–2005)
treated 17 patients for focal infrarenal aortic stenosis with stent grafting with technical success
achieved in 14 out of 17 patients (82%) [1].
Technical success was dened as residual stenosis of <50% or a trans-stenotic systolic pressure
gradient of <10%. Klonaris et al. treated 12
patients from 2003 to 2006 with infrarenal aortic
stenosis and occlusion [2]. They achieved technical success in 91.7% of patients with excess
related hematoma in one patient. They described
two types of aortic stenosis: (A) isolated
infrarenal aortic stenosis/near occlusion near the
origin of the IMA and (B) subtotal occlusion of
distal abdominal aorta with stenosis extending to
both common iliac arteries. The patient described
in this report had a focal severe stenosis at the
origin of the IMA. Infrarenal aortic stenosis at
the site of IMA may lead to occlusion of the IMA
with placement of covered stent. The incidence
of colon ischemia following this procedure is
relatively low. It is possible that due to the small
number of patients reported in the literature the
incidence may be higher; therefore, coverage of
IMA should preferably be avoided in patients
with associated superior mesenteric artery (SMA)
disease or hypogastric artery occlusive disease.
In contemporary practice for subtotal stenosis/
near occlusion in the infrarenal aorta, primary
stenting is preferred treatment for these lesions
and for aortic occlusion [3]. Each patient should
be individualized as the risk in complications
increase in managing total occlusions with endovascular therapy, and for those patients who are
good risk, open aortic reconstruction is preferable. In most series, pre-angioplasty of the lesion
has not been performed due to the risk of distal
embolization, and a primary stenting (bare-metal)
or covered balloon-expandable stents without
pre-angioplasty is preferable.
References
1. Simons PCG, Nawijn AA, Bruijninckx CMA,
Knippenberg B, et al. Long-term results of primary
stent placement to treat infrarenal aortic stenosis. Eur
J Vasc Endovasc Surg. 2006;32:627–33.
2. Klonaris C, Katsargyris A, Tsekouras N, Alexandrou
A, etal. Primary stenting for aortic lesions: from a single stenosis to total aortoiliac occlusion. J Vasc Surg.
2008;47:310–7.
3. Grimme FA, Reijnen MM, Pster K, Martens
JM. Polytetrauoroethylene covered stent placement
for focal occlusive disease of the infrarenal aorta. Eur.
J.Vasc. Endovasc. Surg. 2014;48:545–50.
Covered Bilateral Iliac Artery
Stenting withExtension into
Common Iliac Arteries forNear
Occlusion ofDistal Aorta
92
Physical Examination andHistory
A 58-year-old female with history of chronic
obstructive pulmonary disease (60 pack years),
Addison’s disease, and hypertension was seen in
the outpatient clinic with symptoms of lower
extremity claudication on walking 25–50 yards.
Bilateral femoral pulses were absent, and no
pulses were palpable below that level. Noninvasive
Doppler arterial study showed an ankle brachial
index (ABI) of 0.73 on the right and 0.63 on the
left. She underwent CT angiography which
showed calcic distal aortic stenosis above the
bifurcation with calcication extending along the
posterior wall into the proximal 1cm of the common iliac artery (CIA) on the sides (Fig.92.1).
Fig. 92.1 CTA showing severe calcic stenosis of the distal abdominal aorta with extension into proximal CIA
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_92
413
92 Covered Bilateral Iliac Artery Stenting withExtension into Common Iliac Arteries forNear Occlusion…
414
Procedure
Patient was taken to the hybrid operating room on
May 2, 2019, and using micropuncture technique,
5F sheaths were inserted on both femoral arteries
and a GLIDEWIRE® (Terumo, Tokyo, Japan)
with a Kumpe catheter (Cook Medical,
Bloomington, IN) was advanced into the lower
thoracic aorta from the right side. Similarly, a
Glidewire using Kumpe catheter was advanced
from the left common femoral artery. 5F sheaths
were replaced by 7F sheaths, and on the left side,
an Omniush catheter (AngioDynamics, Latham,
NY) was placed above the level of renal arteries,
and abdominal aortogram was obtained which
showed severe stenosis just above the aortic bifurcation (Fig. 92.2). Omniush catheter was
removed and was replaced with 180 cm-long
angle stiff glidewire. Two covered stents, VBX
8 mm × 39 mm, were deployed in the lower
abdominal aorta with extension into proximal one
third of both the CIA and were raised to 12 atmospheric pressures (Fig.92.3). Completion aortogram via Omniush catheter from the left side
showed satisfactory technical result. Patient had
palpable dorsalis pedis pulse on both sides. Patient
underwent a follow-up noninvasive Doppler arterial study in November 2019 which showed an
ABI of 1.0 on the right and 1.0 on the left.
Discussion
Focal stenosis of the infrarenal abdominal aorta
and/or near occlusion occurs more commonly in
Fig. 92.2 Abdominal aortography showing near occlu-
sion of the distal abdominal aorta
Fig. 92.3 Showing bilateral kissing stents (covered) without residual stenosis
women than men. These patients usually have history of heavy nicotine abuse, hyperlipidemia, and
References
415
premature ovarian failure. Prior to the advent of
endovascular therapy, these patients were managed with aortoiliac endarterectomy and in some
cases with aortofemoral grafting. Both aortoiliac
endarterectomy and aortofemoral grafting are
associated with signicant morbidity (15–20%)
and 2–4% mortality with a prolonged hospital stay
and a long recovery time (2–3months). With the
advent of endovascular therapy, these patients can
be managed with stenting using covered or baremetal stents with excellent results. Covered balloon-expandable stents are preferable as they have
a stronger radial force; however, in patients who
continue to smoke cigarettes, there is a possibility
of in-stent stenosis or the progression of the disease proximally or distally which may require secondary intervention. If the secondary intervention
is not successful, open reconstruction remains a
possibility. As mentioned in the previous chapter, a
number of investigators have reported technical
success of over 90% in patients undergoing stenting for focal aortic stenosis [1–3]. For complete
aortic occlusions, endovascular therapy may not
be feasible in every situation unless the occlusion
is acute or subacute, and thrombolytic therapy is
usually not indicated and is often associated with
risk of complications. In patients with occlusive
disease near the IMA, placement of covered stent
may result in symptoms of colon ischemia in
patients with associated superior mesenteric artery
(SMA) or hypogastric artery occlusive disease. In
this patient with a short follow-up (7 months), satisfactory result was achieved; however long-term
follow-up is necessary as secondary interventions
are not uncommon in patients who continue to
abuse nicotine.
References
1. Simons PCG, Nawijn AA, Bruijninckx CMA,
Knippenberg B, et al. Long-term results of primary
stent placement to treat infrarenal aortic stenosis. Eur
J Vasc Endo Vasc Surg. 2006;32:627–33.
2. Klonaris C, Katsargyris A, Tsekouras N, Alexandrou
A, etal. Primary stenting for aortic lesions: from a single stenosis to total aortoiliac occlusion. J Vasc Surg.
2008;47:310–7.
3. Grimme FA, Reijnen MM, Pster K, Martens
JM. Polytetrauoroethylene covered stent placement
for focal occlusive disease of the infrarenal aorta. Eur
J Vasc Endo Vasc Surg. 2014;48:545–50.
Part XXVI
Percutaneous Intervention for
Infrainguinal Arterial Disease
Percutaneous Intervention
forInfrainguinal Arterial Occlusive
Disease withHeel Ulcer
93
Physical Examination andHistory
A 68-year-old female was admitted to the hospital on January 20, 2018, with a large right heel
ulcer with accompanying cellulitis (Fig. 93.1).
Medical comorbidities included diabetes mellitus
(Type II), stable coronary artery disease, hypertension, peripheral neuropathy, and lumbar ste-
Fig. 93.1 Large ulcer right heel
nosis. She was a former smoker who quit smoking
in 2010. Right heel ulcer (3.5 × 3.5cm) was painful, and cultures revealed Methicillin-resistant
Staphylococcus aureus (MRSA) and gramnegative bacteria. She was given IV vancomycin
and Zosyn. Noninvasive Doppler arterial study
showed severe right infrapopliteal artery occlusive disease with absent ow in the right big toe.
On January 26, 2018, patient underwent right
lower extremity arteriography via left femoral
approach which shows diffuse of mild to moderate stenosis in the right supercial femoral artery
(SFA) and near occlusion of the right popliteal
artery with stenosis of the tibioperoneal trunk
and proximal peroneal artery (Fig.93.2).
Procedure
Patient underwent proximal popliteal artery
angioplasty of the tibial-peroneal trunk and proximal peroneal artery (Figs. 93.2 and 93.3) and
followed by deployment of self-expanding
Supera™ stent (Abbott, Abbott Park, IL).
Completion arteriogram showed satisfactory
result. Patient had SFA plaques with <50% stenosis in the proximal and midsegment which was
not treated. A Supera (5mm × 6 cm) stent was
deployed for popliteal artery occlusion
(Fig.93.4). This resulted in signicant decrease
in the size of the ulceration. Noninvasive Doppler
arterial study on August 31, 2018, showed ankle
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_93
419
420
Fig. 93.2 Showing severe popliteal and infrapopliteal occlusive disease with guidewire and Quick-Cross catheter in
the popliteal artery and peroneal artery
93 Percutaneous Intervention forInfrainguinal Arterial Occlusive Disease withHeel Ulcer
Fig. 93.3 Angioplasty of tibioperoneal trunk and pero-
neal arteries
brachial index (ABI) of 0.44 on the right and 0.64
on the left. As further healing of the ulcer did not
occur as expected, she underwent CTA of the
lower extremities which showed near occlusion
of the proximal SFA, severe stenosis approaching
occlusion of the mid-supercial femoral as well
as distal SFA, and signicant stenosis of the
proximal popliteal artery with patent popliteal
stent (Fig.93.5).
On September 24, 2018, patient underwent
percutaneous intervention of right lower
extremity using left femoral artery access and
advancing a 6 F-45-cm-long PINNACLE®
DESTINATION® sheath (Terumo, Somerset,
NJ). The popliteal stent was patent, but there
was occlusion of the proximal 5–6 cm of the
right SFA; the remaining SFA showed severe
diffuse narrowing with near occlusion in the
midsegment. Popliteal artery stent was patent,
and runoff was present with anterior tibial and
peroneal artery. Using exchange length
GLIDEWIRE® (Terumo) (0.035–260-cm-long)
and a Quick- Cross catheter (Philips,
Amsterdam, Netherlands), attempt was made to
cross the right SFA occlusion, but the wire
advanced into the subintimal plane. An angled
vertebral catheter was used to bring the glide-
Procedure
Fig. 93.4 Post-
deployment of Supera™
stent in the right
popliteal artery
421
Fig. 93.5 Occlusion of right proximal SFA severe stenosis of right mid-SFA and proximal artery patent Supera™ stent
422
93 Percutaneous Intervention forInfrainguinal Arterial Occlusive Disease withHeel Ulcer
wire back into the true lumen. Using vertebral
catheter an exchange length glidewire was
advanced into distal popliteal artery. Attempt was
then made to perform balloon angioplasty over
0.035mm glidewire, but the angioplasty catheter
would not track; therefore we selected a low-prole 0.014300-cm-long BMW wire (Abbott,
Abbott Park, IL) using gradually increasing size
of balloon starting with a 3 mm balloon and
upsizing to 4–5mm balloon with a balloon angioplasty, ultimately with a 5mm × 6-cm-long balloon. This enabled us to exchange the 014 wire
with a 035 glidewire, and we performed angioplasty with a 5mm × 25-cm- long Armada® balloon (Abbott), raising to 8 atmospheric pressure.
This was followed by deployment of two stents:
the rst stent was a self-expanding S.M.A.R.T.
CONTROL stent (Cordis, Hialeah, FL) 6mm ×
15-cm-long just above the Supera stent and the
second one 6 mm × 10-cm- long LIFESTENT®
(Bard, New Providence, NJ) in proximal
SFA. Completion arteriogram showed satisfactory result with residual stenosis of <10%
(Figs. 93.6 and 93.7). Right popliteal stent
(Supera) was patent with two-vessel runoff
(Fig. 93.7). The size of the ulcer decreased
considerably (Fig. 93.8). Arterial Doppler
study shows an ABI of 0.63 on the right and
0.62 on the left in April 2019.
Patient was admitted with multiple small
ulcerations in the right foot and calf in
December 2019. Patient was started on intravenous antibiotics, and noninvasive arterial
Doppler study showed ABI of 0.29 on the right.
Arteriography showed occlusion of right supercial and proximal popliteal artery (stent
thrombosis). However popliteal artery stent
(Supera) remained patent despite proximal
supercial femoral and proximal popliteal
artery occlusion. Runoff arteries were peroneal
as well as anterior tibial artery. However anterior tibial artery occluded at the ankle. Patient
was offered the choice between common femoral-peroneal bypass and amputation. She opted
for the latter, and below-knee amputation was
performed on January 16, 2020.
Fig. 93.6 Post-deployment of SFA and proximal popli-
teal self-expanding stents with residual 20% stenosis in
the SFA
Discussion
In this patient, infrainguinal occlusive disease
represented TASC “C” lesion. Because of
marked obesity with cellulitis in the right calf,
endovascular reconstruction was considered a
better option. Although repeat percutaneous
intervention became necessary, it was considered superior to open arterial bypass. Because
of the large size of her thigh and calf with
chronic cellulitis changes in the right lower
Discussion
Fig. 93.7 Patent popliteal artery stent with two vessel
runoff
Fig. 93.8 Ulcer of the right foot 1 year later
423
extremity, the risk of surgical site infection
would be extremely high. In addition, the quality of the greater saphenous vein (GSV) in this
patient was inadequate. At the present time,
patient is undergoing aggressive local wound
care at the wound care center, and once complete healing of the ulcer is obtained, it is conceivable that even if the recurrence develops in
this patient (likely), repeat percutaneous intervention may not be necessary as patient has limited ambulation potential.
The natural history of chronic limb ischemia
compared with symptoms of intermittent claudication is signicantly worse with >25% of
patients needing major amputation within 1 year
[1]. An endovascular rst approach has been
adopted by many vascular surgeons, although
limited number of studies exist directly comparing open bypass with endovascular therapy [1].
The BASIL bypass versus angioplasty trial in
severe ischemia of the leg was studied in the
United Kingdom. They concluded that there was
no signicant difference at 2 years in amputationfree survival or quality of life measures between
those undergoing angioplasty compared to
bypass surgery for critical limb ischemia [1]. The
surgery group resulted in one third greater costs
than the angioplasty group at 1 year. By 3 years,
this difference was no longer signicant because
of the greater need for reintervention in the
angioplasty group [1].
Retrograde tibial or pedal access is an additional option if the ipsilateral femoral or the contralateral femoral approach is not feasible in
crossing the stenotic or occlusive lesions in the
femoral popliteal and infrapopliteal arteries.
Antegrade recanalization of infrapopliteal occlusion may be unsuccessful in up to 20% of patients
with critical limb ischemia [2]. Access dorsalis
pedis or posterior tibial at the ankle can be
obtained using micropuncture access under ultrasound guidance [2, 3]. The foot should be placed
in plantar exion for access to dorsalis pedis and
inversion for distal peroneal artery [3]. Lesion is
crossed by 0.01 × 8 mm wire (bare back) as a
support for a 2.0 × 2.5mm balloon [3]. Antegrade
access can be used to treat any lesion that requires