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Angiotensin-convertingenzyme(ACE)inhibitororangiotensinreceptorblocker(ifintolerant,dihydropyridinecalciumblockers)
Aldosteroneinhibitors(withmonitoringofserumpotassium)
Idealdiet
Sodiumrestriction
Weightcontrol
Aerobicexercise
Smokingcessation
B.GuidelinesandIndications
1. Exisiting 2005 (updated 2011,2014) guidelines continueto suggest revascularization as a Class I
indicationforhemodynamicallysignificantrenovasculardiseasewithrecurrentunexplainedheartfailure
orflashpulmonaryedema.
3,60,92
2. Class IIa indications include renovascular disease with either accelerated, resistant, or malignant
hypertension,orhypertensionwithunilateralsmallkidney,orhypertensionwithmedicationintolerance.
AdditionalClassIIaindicationsarerenalimpairmentwithbilateralrenovasculardiseaseorrenovascular
diseaseinasolitarykidney,aswellasrenalarterydiseaseandunstableangina.
3,60
3. Class IIbindications includeasymptomaticbilateralrenovasculardisease orsolitaryviable kidney
with hemodynamically significant renovascular disease, asymptomatic unilateral hemodynamically
significantrenovasculardiseaseinaviablekidney,andrenovasculardiseaseandrenalimpairmentwith
unilateraldiseaseinasettingwheretwokidneysarepresent.
3,60
XVII.Summary
In thecontextofrenovasculardisease,ifblood pressureregulationcannotbeachieved,ifloss ofrenal
function is progressing, or if circulatory congestion is prominent, then renal revascularization is
reasonable.20 Otherwise, intensive optimized medical and lifestyle therapyshould be pursued(Table
8.3).
Whethernew catheter-based techniques suchas renal denervation(forhypertension ornumerousother
adrenergicallydrivencardiovascularconditions)willaffordtruebenefitsmustawaitfutureprospective
randomizedtrialresultsandanticipatedtechnologicaladvances.
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C H A P T E R 9
EndovascularInterventionofAortoiliac
OcclusiveDisease
SasankaJayasuriyaMBBSFACCFASERPVIFSCAIandWilliamL.Bennett,MD,PhD
I.Introduction
II.IndicationsforEndovascularInterventionofAortoiliacOcclusiveDisease
A.Claudication
B.Criticallimbischemia
C.Erectiledysfunction
D.Vascularaccess
III.Diagnosis
A.Physicalexamination
B.Physiologictesting
C.Imaging
IV.EndovascularTreatment
A.ProcedurePlanning
B.Access
V.CommonFemoralDisease
VI.LesionCrossing
A.ExternalIliacArteryandRetrogradeApproach
B.AntegradeApproach
C.CommonIliacArteryOcclusions
D.InfrarenalandDistalAorticOcclusions
VII.Reentry
A.Successofsub-intimalcrossing
B.Standardwireandcatheterstrategy
C.Subintimalwire-trackingoftheiliacartery
D.Retrogradewireadvancementtechnique
E.Pioneercatheter
F.Outbackcatheter
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G.Requirementforreentrydevices
VIII.AngioplastyandStentPlacement
A.Standardofpractice
B.Studies
C.EndovascularinterventionsforAIOD
D.Lesions
E.Occlusions
IX.Patency
X.Complications
A.Ruptures
B.Arterialdissection
C.Distalembolization
D.Acutestentmisadventures
E.Latecomplications
XI.Follow-Up
A.Medicaltherapy
B.Regularintervals
XII.Summary
KeyPoints
■Claudication, critical limb ischemia, and erectile dysfunction are symptoms related to
aortoiliacocclusivedisease.
■Investigations including ABI ultrasound are performed to aid diagnosis, and CT
angiographyandMRAarehelpfulforlesioncharacterizationandprocedureplanning.
■Many techniques including contralateral and ipsilateral crossing techniques could be
undertakenforcrossingthelesionwithreentrydevicesusedtoaidaccesstothetruelumen.
■Self-expanding stents are commonly used with 3-yearprimarypatencybeing greater than
70%.
I.Introduction
Advances in transcatheter therapies have led to a shift in endovascular interventions for aortoiliac
disease,eveninthesettingofcomplexlesionssuchasTrans-AtlanticInter-SocietyConsensusDocument
classification(TASC)class CandDlesions inrecenttimes.1Patientswithperipheralarterialdisease
suffer from multiple comorbidities, andup to40% suffer from significant coronary arterydisease. Of
thesepatients,thesubgroupsufferingfromaortoiliacocclusivedisease (AIOD) suffersfromsubstantial
lossofqualityoflifeowingtoclaudicationandcriticallimbischemia.11Endovasculartreatmentoptions
areavaluablealternativetohigh-riskopensurgicalprocedures.However,theoperatorsareencouraged
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torecognizethe risks associated with aortoiliac interventions withattention to careful case selection,
procedureplanning,technicalskill,andbailoutstrategies,whichresultinsuccessfulresults.
II.IndicationsforEndovascularInterventionofAortoiliac
OcclusiveDisease
A.ClaudicationisacommonsymptominAIODwithcomplaintsincludingclaudicationofthebuttocks,
thighs, or calf. Symptoms typically begin in the calves and proceed proximally with worsening
hemodynamics. Intervention is indicated when >50% stenosis is present with lifestyle-limiting
claudication(Rutherfordclass2and3),whichisnotimprovedwithmedicaltherapyorexercisetherapy.
Intheeventofmultileveldisease,inflowrevascularization(treatmentofAIOD)isundertakeninitially.
B. Critical Limb Ischemia presenting as ischemic rest pain or vascular ulcers and tissue loss
(Rutherford class 4, 5, and 6) is a strong indication for revascularization. Contrary to patients with
claudication, patients with critical limb ischemia are treated with complete revascularization in an
attempttoestablishstraight-linereperfusiontotheaffectedangiosome.
C.ErectileDysfunctionisanotherindicationfortreatmentofAIOD.Thetypicalsyndromeofbuttockor
thighclaudication,erectiledysfunction,andabsentpulsesisknownas Lerichesyndromeandisusually
causedbyAIOD.
D. Vascular Access for unrelated procedures such as endovascular aortic repair (EVAR) and
transcatheteraorticvalvereplacement(TAVR)requiringlarge-diametersheathintroductionmayrequire
aortoiliacrevascularization.
III.Diagnosis
A. Physical Examination performed thoroughly could suggest AIOD, although the nature and exact
locationofthelesioncannotbepredicted.Reducedorasymmetricfemoralpulsesareappreciatedwith
typical signs of chronic ischemia in the affected limb such as cold extremity, pallor, hair loss, nail
atrophy,anddependentrubor.
B.Thefirstlineofphysiologictestingincludesnoninvasivetestingsuchasanklebrachialindex(ABI),
toe brachial pressures, segmental pressures, and pulse volume recording (PVR). If unilateral iliac
stenosisispresent,theABI,segmentalpressures,aswellas thePVRwouldbe reduced intheaffected
limb.However,inthesettingofdistalaorticorbilateralaorticdisease,theABIandsegmentalpressures
maybe reduced ina symmetrical fashion.Blunting of the pulse volume waveform bilaterallysuggests
distalaorticandbilateraliliacdisease.
C.Imaging
1.Duplexultrasoundcouldbeusedasamethodofimagingespeciallyinpatientswithrenalimpairment.
However, iliac ultrasound evaluation is technicallychallenging and time-consuming with poor images
resultingduetobodyhabitus,bowelgas,andcalcification.AstudybyUbbinketalsuggestedsignificant
interobservervariabilitywith iliacdupleximagingwith1/8 agreementonresults.12Hence, alternative
imagingshouldbeconsideredifmorepreciseanatomicdiagnosesareneeded.
2. Computer tomography angiography (CTA) is an excellentstudy modalityinpatients withAIOD.
Currentgenerationscannersproduceaccuratethree-dimensionalimagingandareanexcellentalternative
toinvasiveangiographyforplanningrevascularization.BenefitsofCTAevaluationincludeafasterscan
time, high spatial resolution, and ability to visualize in-stent restenosis. However, use of iodinated
contrast and radiation exposure are disadvantages, and further heavily calcified vessels may reveal
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inaccuratelymoreseverestenosisduetobloomingartifact.
3. Magnetic resonance angiography (MRA) is another effective imaging method of evaluation in
AIOD. Current high-performance MR scanners produce remarkable angiography. MRA carries the
benefitsofnotbeingexposedtoiodinatedcontrastorionizingradiation.Howeverimageacquisitiontakes
alongtime,andpatientswithadvancedrenaldiseaseareatriskofnephrogenicsystemicfibrosis.MRA
alsomaynotaccuratelyestimatethedegreeofcalcification,whichmaychangethelevelofcomplexityof
anintervention.
4. Invasive angiography is the gold standard for imaging aortoiliac disease. In assessing AIOD, the
initialangiogramwouldcompriseofananterior-posteriordistalaorticangiogramrunofftoincludeboth
common iliac, external iliac, and common femoral arteries (CFAs). Imaging is performed by digital
subtractionangiography(DSA).
a. Evaluationofeachiliacarteryisperformedbycontralateralobliqueprojection,whichseparatesthe
iliac bifurcation. In the event ofa long-segment occlusion,the distal anastomotic site as well as
below knee run off is completed to ensure the appropriate approach is undertaken and distal
embolizationhadnotoccurredduringintervention.
b. The hemodynamicsignificanceofanintermediatelesion canbemeasuredbyadvancing acatheter
beyond the lesion with gradual pullback measurements. A more accurate method is to transduce
simultaneously the side branch of the sheath and a catheter, which is at least 1 French less in
diameter placed across the lesion. A peak-to-peak systolic gradient greater than 10 mm Hg is
consideredtobehemodynamicallysignificant.Withconcomitantdistaldisease,apressuregradient
couldbeinducedwithintra-arterialnitroglycerininjectiontoinduceperipheralvasodilatation.
IV.EndovascularTreatment
A.ProcedurePlanning
PlanningoftheprocedureisakeyelementinendovasculartreatmentofAIOD.Specificpatientandlesion
characteristicscouldsignificantlychangetheapproachandoutcomesinintervention.
1.Lesioncharacteristics.Long-segmentocclusionsandheavilycalcifiedvesselsshouldbeundertaken
only by the experienced operator. For early career interventionalist, backup support planning is
imperative.Whileheavycalcificationisacontraindicationtoaortoiliacpercutaneousintervention,every
lesion carries the risk of perforation. Hence the availability of bailout equipment such as occlusive
balloonsandcoveredstentsshouldbeensured.
2.Patientcharacteristics.AIODinterventioncouldberelativelyfastorlongandcomplex.Hencethe
candidacyforconscioussedationandsupportfromananesthesiologistshouldbeassessed.Considering
the higher volume of iodinated contrast used, prehydration should be undertaken to reduce contrastinduced nephropathy with special attention to the patient’s current volume status and left ventricular
function.Low-osmolaroriso-osmolarcontractagentuseisalsoassociatedwithalowerriskofcontrastinducednephropathy.
B.Access
1.Accesssiteandsheathsizeareimportantdecisionsthatlaythefoundationtosuccessfulcompletionof
the intervention. Complex aortoiliac intervention usually requires dual access. While angiography is
performed through catheters advanced from one site, equipment would usuallybe delivered througha
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largerFrenchsheathinanalterativesite.
2.ThemostcommonsiteofaccessinAIODistheipsilateralCFA.However,intheeventofcomplete
occlusionoftheexternaliliacartery,theremaynotbeanadequatelengthinthepatentvesseltoadvance
the sheath. In this case, contralateral commonfemoral access or brachial access is considered. While
radialaccessismoreelegant,incomparisontobrachialaccess,theshaftlengthofcurrentballoonsand
stents may not reachtheexternal iliac vessels from a radial sheath.However,forthe sole purpose of
diagnostic angiography proximal to the occlusion, radial access could be obtained, through which a
pigtailcatheterplacedinthedescendingaortaoramultipurposecatheterdirectedtotherespectiveiliac
arterywouldbeusefultoperformdiagnosticangiography.However,ifdevicesaretobedeliveredfrom
above,brachialaccessisrequired.Leftbrachialaccessispreferredastheriskofcerebralembolization
islessthanwithrightbrachialaccessinthesepatientswithsignificantatheroscleroticdisease.
3. Indecidingsheathsize,the smallestsheath,which wouldallow requiredequipmentdelivery, isthe
choice. However,ina heavilycalcified vessel, a sheaththat could deliver acovered stentas needed
wouldbeawiserchoice.
V.CommonFemoralDisease
In theeventofconcurrentcommonfemoral disease,aprior decision for the approachtomanagingthis
lesion is imperative. At the conclusion of the iliac intervention, the lesion in the CFA could be
revascularized by atherectomy and drug coated balloon therapyor with hybrid revascularization with
concomitantcommonfemoralendarterectomy.
VI.LesionCrossing
A.ExternalIliacArteryandRetrogradeApproach
Occlusions of theexternal iliac arterycould be crossed byipsilateral common femoral access, if the
distal external iliac arterywas patent and sheathplacement was possible. Ultrasound-guided vascular
accessisbeneficial,asfemoralpulsesarefainttoabsent.Abright-tippedsheathisused.Thelesioncould
be crossed with an assortment of wires and backup catheters. We commonly use a 0.14″ Fielder FC
(AsahiIntecc)wirewithaQuickcross(SpectraneticsCorp,ColoradoSprings,CO)backupcatheterwith
success in crossing the lesion in an intraluminal fashion. However, an angled Glidewire (Terumo
Medical, Somerset,NJ) anda 0.35 ″angled backup catheterare otheroptions.The supportcatheteris
advancedtothedistal capofthe occlusion with gentleforwardforce,andthedistalcapiscrossedby
spinningor loopingthe wire.Asthe access sheathcouldget displacedout oftheartery when forward
forceisappliedtocrossthelesion,itshouldbesecuredmanually.Subintimalcrossingmaybeundertaken
with the Glidewire, but reentering the vessel at the reconstitution site is important to prevent undue
stenting and propagation of a dissection plane. Once the lesion is crossed, the backup catheter is
advanced beyond the lesion and blood is aspirated to confirm intraluminal placement. A limited
angiogramcouldbeperformedthroughthebackupcatheter.Astiff-bodiedwireisthenadvancedthrough
the backupcatheter,which wouldbe theguidewire forequipmentdelivery tocompletethe procedure.
Hencethiscouldbea0.14″,0.18″,or0.35″wiredependingontheinterventionplanned.
B.AntegradeApproach
An external iliac occlusion could also be crossed by the antegrade approach with access in the
contralateral CFAor intheleftbrachial artery. Withcontralateral CFAaccess, the iliac bifurcationis
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crossed in standard fashion, and a 45 cm crossover sheath is advanced to the proximal cap of the
occlusion. With angiography performed in the contralateral oblique position, the lesion is crossed as
mentionedabove.
Withbrachialaccessa90cmguidingsheathisadvancedtotheproximalcapofthelesion.Thelesionis
crossedwithwireandabackupcatheter,andthestiffguidingwireisplacedintheCFA.Withavailable
landingroominthedistalexternaliliacandCFAs,thewireadvancedfromthebrachialpositioncouldbe
externalized through a sheathin theipsilateral CFA. This could be exchanged to a stiffguidingwire,
followingwhichtheinterventioncouldbecompletedfromtheipsilateralCFA.
C.CommonIliacArteryOcclusions
Occlusions of the common iliac artery or common and external iliac arteries are best crossed by
ipsilateral CFA access or left brachial access. Contralateral crossover sheaths usually would not be
stable enough to provide the backup support or “pushability” to cross through a lesion. This is
specificallytrue in flushocclusionsoftheostial commoniliacartery, althoughthisapproach could be
triedasaninitialstrategy,asaccessislikelyobtainedfordiagnosticangiography.Oncetheguidingsheath
isusuallyadvancedtoengagethestumporinverycloseproximityofthelesion,whichiscrossedwitha
hydrophilicguidewireandangledbackupcatheter.A0.14″wiresuchastheFielderFC(AsahiIntecc)or
a0.35″angledGlidewire(TerumoMedical,Somerset,NJ)couldbeused.Ifbrachialaccesswasused
thewireissnaredoutofasheathplacedintheipsilateralCFA,thusallowingforastiffguidingwiretobe
advancedtothedescendingaortafromtheCFA,whichfacilitateseaseofdeliveryofstentsandcorrect
alignment.
D.InfrarenalandDistalAorticOcclusions
Occlusionoftheinfrarenalaortaandaortoiliacbifurcationoftenrequirebilateralaccessduetothelikely
need of kissing stents. Althougha retrogradecrossingstrategyasdiscussed above could beundertaken
followingaccessinbilateralCFAs,brachialaccessremainsareasonablealternative.Ifthelesionsare
crossed in antegrade fashion from the brachial artery access point, the wires could be externalized
through the respective sheaths in the CFA. Brachial access also minimizes subintimal tracking in the
descending aorta and consequently the need for reentry devices in the descending aorta. However,
brachialaccesscarriesthehighestriskofaccesssitecomplicationswithhematoma,pseudoaneurysm,and
thrombosis.
VII.Reentry
A.Thesuccessofsubintimalcrossingliesinreentry.Althoughanangledbackupcathetercouldhelpto
directthe wiretoward thetruelumen, the operatorshould changetheangle ofimaging asthelesionis
crossedtoensurethewireadvancementfavorsreentry.
B.Whilethemajorityofvesselsarereenteredwithstandard wire and catheterstrategy somecases
requiremorecomplexstepssuchasantegradecrossingoruseofreentrydevices.
C.Incaseofsubintimalwire-trackingoftheiliacartery,anattemptismadetocrossthelesionwitha
second wire in an antegrade fashion. This maneuver could be undertaken with contralateral femoral
access orbrachialaccess.Astheantegradewire isadvancedina newsubintimalplaneand meets the
retrogradewire,theretrogradewirewouldfollowthepathoftheantegradewireandadvancetothetrue
lumen.
D.However, instead of the retrograde wire advancement technique, one could opt to use reentry
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