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6.5 Evidence for Early Mobilisation

Much of the literature supporting the use of closure-devices

cites the reduced time to mobilisation following their use

compared with manual compression. This, however, simply

reﬂects the pre-determined protocols used in the various

trials: those patients allocated manual compression follow a

protocol which speciﬁes a longer period of bed-rest than

those randomised to closure devices. Thus it is a foregone

conclusion that use of a closure device will be associated

with reduced time to mobilisation.

There is little evidence to underpin the bed-rest regimes

that most centres follow. A meta-analysis of the controlled

trials comparing longer versus shorter periods of bed-rest

found thatshorter periodsof bed-restwere notassociated with

greater risk of complications (Allen et al. 1999). Indeed, side

effects (mainly back pain) were increased by a longer dura-

tion ofbed-rest. Allavailable evidence thereforesuggests that

even with manual compression, the shorter the duration of

bed-rest the better. This factwasnot unknown to thepatriarch

of interventional radiology, Charles Dotter, who wrote in

1960, when diagnostic catheter sizes were considerably lar-

ger thantoday’s, ‘‘…patients arekept under observation until

they areable to walk freely without causing bleeding, usually

10–15 min after application of the dressing’’ (Dotter 1960).

Our experience of day-case interventional procedures

using sheathsof up to 7 F suggests that same-day discharge is

safe in the great majority of patients when using manual

compression alone. All puncture site complications in our

series were apparent within 4 h of the procedure (Butterﬁeld

et al. 2000).

In summary, the routine use of closure devices deﬁnitely

reduces the time to achieve haemostasis following arterial

puncture. This appears to be at the cost of an increased risk

of complications which are sometimes serious. Further-

more, the evidence that patients can be mobilised earlier is

poor. The routine use of closure devices is therefore ques-

tionable. There remain selected subgroups in whom closure

devices are of undoubted beneﬁt and in whom their use

should be encouraged.

References

Al-Kutoubi A, De Jode M, Gibson M (1996) Radial artery approach

for outpatient peripheral arteriography. Clin Radiol 51:110–112

Allen C, Glasziou P, Del-Mar C (1999) Bed rest: a potentially harmful

treatment needing more careful evaluation. Lancet 354:1229–1233

Archbold AR, Robinson NM, Schilling RJ (2004) Radial artery access

for coronary angiography and percutaneous coronary intervention.

BMJ 329:443–446

Arthurs ZM, Starnes BW, Sohn VY et al (2008) Ultrasound-guided

access improves rate of access-related complications for totally

percutaneous access-related complications for totally percutaneous

aortic aneurysm repair. Ann Vasc Surg 22(6):736–741

Barbeau GR, Arsenault F, Dugas L et al (2004) Evaluation of the

ulnopalmar arterial arches with pulse oximetry and plethysmogra-

phy: comparison with the Allen’s test in 1010 patients. Am Heart J

147:489–493

Boston US, Panneton JM, Hofer JM et al (2003) Infectious and

ischaemic complications from percutaneous closure devices used

after vascular access. Ann Vasc Surg 17:66–71

Butterﬁeld JS, Fitzgerald JB, Razzaq R et al (2000) Early mobilization

following angioplasty. Clin Radiol 55:874–877

Carey D, Martin JR, Moore CA et al (2001) Complications of femoral

artery closure devices. Catheter Cardiovasc Interv 52:3–7

Chrisman HB, Liu DM, Bui JT et al (2005) The safety and efﬁcacy of a

percutaneous closure device in patients undergoing uterine artery

embolisation. J Vasc Interv Radiol 16:347–351

Cowling MG, Buckenham TM, Belli A-M (1997) The role of

transradial angiography. Cardiovasc Intervent Radiol 20:103–106

Das R, Ahmed K, Athanasiou T et al (2011) Arterial closure versus

manual compression for femoral haemostasis in interventional

radiological procedures: a systematic review and meta-analysis.

Cardiovasc Intervent Radiol 34:723–738

Dotter CT(1960) Leftventricular andsystemic arterialcatheterization: a

simple percutaneous method using a spring guide. Am J Roentgenol

Radium Ther Nucl Med 83:969–984

DudaSH, Wiskirchen J, ErbM et al(1999) Suture-mediatedpercutaneous

closure of antegrade femoral arterialaccess sites in patients whohave

received full anticoagulation therapy. Radiology 210:47–52

Estes JM, Halin N, Kwoun M et al (2001) The carotid artery as

alternative access for endoluminal aortic aneurysm repair. J Vasc

Surg 33:650–653

Foran JP, Patel D, Brookes J et al (1993) Early mobilisation after

percutaneous cardiac catheterisation using collagen plug (Vasoseal)

haemostasis. Br Heart J 69:424–429

Hartnell G (1998) An imporved reversal technique from retrograde to

antegrade femoral artery cannulation. Cardiovasc Intervent Radiol

21(6):512–513

Heenan SD, Vinnicombe SJ, Buckenham TM et al (1994) Percutane-

ous transluminal angioplasty by a retrograde subintimal transpop-

liteal approach. Clin Radiol 49:824–828

Henry GA, Williams B, Pollak J et al (1999) Placement of an

intracoronary stent via translumbar puncture. Catheter Cardiovasc

Interv 46:340–342

Jolly SS, Yusuf S, Cairns J et al (2011) Radial versus femoral access

for coronary angiography and intervention in patients with acute

coronary syndromes (RIVAL): a randomized parallel group,

multicenter trial. Lancet 377:1409–1420

Kessel DO, Robertson I, Edward JT et al (2003) Renal stenting from

the radial artery: a novel approach. Cardiovasc Intervent Radiol

26:146–149

Koreny M, Riedmüller E, Nikfardjam M et al (2004) Arterial puncture

closing devices compared with standard manual compression after

cardiac catheterization: systematic review and meta-analysis.

JAMA 291:350–357

Lienemann A, Werle K, Weigert F (1993) Die transbrachiale arterielle

Katheter-Angiographie. Technik, Indikationen, Komplikationen,

Radiologie 33:102–107

Malkawi AH, Hinchcliffe RJ, Holt PJ et al (2010) Percutaneous access

for endovascular aneurysm repair: a systematic review. Eur J Vasc

Endovasc Surg 39(6):676–682

May J, White GH, Waugh R et al (2000) Common carotid artery access

for endoluminal aortic aneurysm repair. J Endovasc Ther 7(1):

1–24

Michel C (2004) Artériographie diagnostique par voie transradiale.

J Radiol 85:783–786

Murray D, Ghosh J, Khwaja N et al (2005) (2005) Staged open and

endovascular repair of thoracoabdominal aneurysms using the

common carotid artery. Ann Vasc Surg 19(1):103–107

50 J. K. Bell and N. Chalmers

https://t.me/med1917

Nikolsky E, Mahran R, Halkin A et al (2004) Vascular complications

associated with arteriotomy closure devices in patients undergoing

percutaneous coronary procedures: a meta-analysis. J Am Coll

Cardiol 44:1200–1209

Nicholson T, Ettles D, Robinson G (2004) Managing inadvertent

arterial catheterization during central venous access procedures.

Cardiovasc Intervent Radiol 27:21–25

Noor S, Meyers S, Curl R (2010) Successful reduction of surgeries

secondary to arterial access site complications: a retrospective

review at a single centre with an extravascular closure device. Vasc

Endovascular Surg 44(5):345–349

Ohrlander T, Sonesson B, Ivancev K et al (2008) The chimney-graft: a

technique for preserving or rescuing aortic branch vessels in stent-

graft sealing zones. J Endovasc Ther 15(4):427–432

Reekers JA, Müller-Hülsbeck S, Libicher M et al (2010) CIRSE

vascular closure device registry. Cardiovasc Intervent Radiol 34:

50–53

Saito S, Ikei H, Hosokawa G et al (1999) Inﬂuence of the ratio

between radial artery inner diameter and sheath outer diameter on

radial artery ﬂow after transradial coronary intervention. Catheter

Cardiovasc Interv 46:173–178

Saha S, Gibson M, Magee TR et al (2001) Early results of retrograde

transpopliteal angioplasty of iliofemoral lesions. Cardiovasc Interv

Radiol 24:378–382

Seldinger S (1953) Catheter replacement of the needle in percutaneous

arteriography. Acta Radiol 39:368–376

Spiliopoulos S, Katsanos K, Diamantopoulos D et al (2011) Does-

ultrasound guided lignocaine injection improve local anaesthesia

before femoral artery catheterization? Clin Radiol 66:449–455

Spinosa DJ, Harthun NL, Bissonette MS et al (2005) Subintimal

arterial ﬂossing with antegrade-retrograde intervention (SAFARI)

for subintimal recanalization to treat chronic critical limb ischae-

mia. J Vasc Interv Radiol 16:37–44

Tønnesen KH, Sager P, Karle A et al (1988) Percutaneous transluminal

angioplasty of the superﬁcial femoral artery by retrograde catheteri-

sation via the popliteal artery. Cardiovasc Interv Radiol 11:127–131

Vaitkus PT (2004) A meta-analysis of percutaneous vascular closure

devices after diagnostic catheterisation and percutaneous coronary

intervention. J Invasive Cardiol 16(5):243–246

Wagner SC, Gonsalves CF, Eschelman DJ et al (2003) Complications

of a percutaneous suture-mediated closure device versus manual

compression for arteriotomy closure: a case-controlled study.

J Vasc Interv Radiol 14:735–741

Watkinson AF, Hartnell GG (1991) Complications of direct brachial

artery puncture for arteriography: a comparison of techniques. Clin

Radiol 44:189–191

Yilmaz S, Sindel T, Erdogan A et al (2002) Hematoma after

percutaneous transpopliteal stenting and remote suturing of the

popliteal artery. J Endovasc Ther 9:703–706

Zealley I, Chakraverty S (2005) Routine US guidance for arterial

access in angiography substantially reduces both the time taken and

the number of needle passes required. Submitted to RSNA 2005

Sites of Arterial Access 51

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Aortoiliac Intervention

Rafiuddin Patel and Anthony A. Nicholson

Contents

1 Introduction.......................................................................... 53

2 The Evidence for Aortoiliac Intervention ........................ 53

2.1 Open or Endovascular Surgery

for Symptomatic Aortoiliac Disease? ................................... 54

2.2 When Is a Lesion Significant?.............................................. 57

2.3 Angioplasty or Stent? ............................................................ 58

2.4 What Conclusions Can We Draw from the Evidence? ....... 59

3 Technical Aspects ................................................................ 59

3.1 Aortoiliac Stenotic Disease................................................... 60

3.2 Chronic Iliac Occlusions....................................................... 60

4 Complications of Iliac Angioplasty and Stenting ............ 62

4.1 Puncture-Site Complications ................................................. 62

4.2 Arterial Rupture ..................................................................... 63

4.3 Embolization.......................................................................... 64

4.4 Stent-Related Complications ................................................. 64

5 Future Technologies ............................................................ 66

6 Conclusion ............................................................................ 66

References...................................................................................... 66

Abstract

Iliac artery angioplasty and stenting are widelyconsidered

the classical and deﬁning endovascular interventions

performed for patients with peripheral vascular disease,

offering comparable outcomes to surgery with reduced

morbidity and mortality. We evaluate the accumulated

evidence base for aortoiliac intervention and present the

salienttechnicalaspects, potentialcomplications and‘bail-

out’ techniques that the operator should be familiar with.

Future technologies on the horizon to address the problem

of post-intervention restenosis are also considered.

1 Introduction

The ﬁrst peripheral angioplasties performed byCharles Dotter

in 1964 were carried out in the superﬁcial femoral artery.

However, following the introduction of balloon angioplasty it

is probably true to say that aortoiliac angioplasty and stenting

has come to deﬁne peripheral vascular intervention. This is

largely because these segments were the ﬁrst areas in which

early evidence suggested comparable outcomes with surgery

but with reduced morbidity and mortality. Endovascular

interventional techniques have now redeﬁned traditional

treatment options for aortoiliac occlusive disease and clini-

ciansand patients alikehaveenthusiasticallyacceptedthiswith

a substantial increase in aortoiliac angioplasty andstentingand

a corresponding decline in the number of patients undergoing

aortofemoral bypass surgery (Upchurch et al. 2004).

2 The Evidence for Aortoiliac

Intervention

When considering the accumulated evidence for any

therapeutic intervention, consideration should be given to

whether randomised controlled trials (RCT’s) and obser-

vational studies are mutually exclusive. To evaluate this

R. Patel  A. A. Nicholson (&)

Vascular Radiology,

Leeds Teaching Hospitals NHS Trust,

Great George Street, Leeds LS1 3EX, UK

e-mail: tonynick@tonynick.demon.com

M. G. Cowling (ed.), Vascular Interventional Radiology, Medical Radiology. Diagnostic Imaging,

DOI: 10.1007/174_2011_515, Ó Springer-Verlag Berlin Heidelberg 2012

https://t.me/med1917

requires some knowledge of why interventional radiologists

and vascular surgeons turned so rapidly to percutaneous

iliac intervention and why iliac stenting had such an impact

from 1990 onwards. Both have been used to evaluate the

question such different techniques pose. There are those

who would dismiss observational studies on the basis that

RCT’s are seen as more reliable estimators of how well

a treatment works. There is however evidence that obser-

vational studies do not over-estimate the size of treatment

effect when compared with their randomised counterparts

(Benson and Hartz 2000; Concato et al. 2000). In many

instances concordance is in fact better between RCT’s and

observational studies than that observed when meta-analysis

of small randomised trials are compared to the results of

large randomised trials (Lau et al. 1998). This is probably

because concordance is not perfect within these studies and

also because variability previously seen as a nuisance factor

may in fact simply mean that where randomised trials are

studying diverse patient populations, observational studies

are amalgamating larger populations to reach average

population wide effects with less variability but more

uncertainty about which subgroup is likely to beneﬁt.

For interventions that show very large harmful effects in

observational studies, randomised trials may be justiﬁably

discouraged and never performed. Similarly for interven-

tions that have already shown large beneﬁcial treatment

effects in observational trials the ethics of randomisation

may also be questioned. Conversely, interventions with

mild postulated effects should be subject to randomised

trials although it would be wrong not to give observational

studies comparable credit and to discard such evidence.

Clearly there are also interventions with such small postu-

lated effects that adequately powered randomised trials

would not be possible to perform because of the required

sample size. Here, only observational evidence may be

generated (Ioannidis et al. 2001).

Where does aortoiliac evidence ﬁt into this paradigm?

There are two aspects to the evidence; the choice between

endovascular versus open surgical reconstruction and

angioplasty versus stent.

2.1 Open or Endovascular Surgery

for Symptomatic Aortoiliac Disease?

There are a great many observational studies in the litera-

ture, which suggest that both surgery and endovascular

treatment are safe and efﬁcacious in the aortoiliac segments.

However, the clinical differences shown are not great.

Therefore RCT’s should be the standard by which we

decide which is best. There is only one RCT that has

compared open surgery to angioplasty in symptomatic iliac

disease (Wolf et al. 1993). In this study 263 men with iliac

disease contributing to either rest pain or lifestyle-limiting

claudication were randomised to either surgery or angio-

plasty. Of these patients 126 underwent bypass surgery and

129 patients underwent angioplasty. There were 3 deaths in

the group that underwent surgery and none in the angio-

plasty group. Primary success favoured open surgery but

limb salvage favoured angioplasty, although these differ-

ences were not statistically signiﬁcant. Patients in both

groups had prompt and sustained improvement in haemo-

dynamics and quality of life and no signiﬁcant difference in

outcome in a median follow up of 4 years. This study

clearly favours angioplasty as outcomes between the two

treatments are no different but the morbidity and mortality

is higher in the open surgical group. It is a study of one

particular subgroup. There were no women in the study and

traditionally they have smaller arteries which are more

difﬁcult to treat. However, this is true for both surgery and

for endovascular treatment. In addition there are numerous

compounding variables which the study has not taken into

account. In a randomised study of this size it is impossible

to perform sub-group analysis on those with co-morbid

conditions such as diabetes, heart disease, hypertension,

renal failure or those with more proximal or more distal

disease.

In a second, non-randomised comparative study the

complication rate, primary patency and cost of stent

deployment were compared with direct surgical recon-

struction for the treatment of severe aortoiliac occlusive

disease (Ballard et al. 1998). A total of 65 patients under-

went stent deployment and 54 patients had surgical recon-

struction. Statistical analysis found no signiﬁcant difference

between the groups in terms of clinical, demographic or

presentational features and there were no signiﬁcant dif-

ferences in late complications. However, the cumulative

primary patency rate for bypass grafts was signiﬁcantly

better than for iliac stents at 18 months (93 vs. 73%),

30 months (93 vs. 68%) and 42 months (93 vs. 68%).

Multi-variate analysis suggested that females, anyone with

ipsilateral superﬁcial femoral artery occlusion and anyone

who had procedure-related vascular complications and

hypercholesterolemia were more likely to thrombose their

bypass graft or stent. Costs did not differ signiﬁcantly.

So above we have presented two studies with very

different conclusions. The ﬁrst is a randomised and the

second an observational study. It is difﬁcult to determine

which of the many variables in the observational study

affected which group, and it is of course possible that

patients who were less ﬁt for open surgery or who had

less favourable distal run-off were treated by endovascu-

lar means.

A recently published, retrospective, non-randomised

single-centre comparison of aortobifemoral bypass and

aortoiliac stenting (Burke et al. 2010) performed over

54 R. Patel and A. A. Nicholson

https://t.me/med1917

11 years, found surgical bypass was associated with

signiﬁcantly increased early complications including the

need for emergency surgery, higher infection rates, trans-

fusion requirements, intensive care needs and lymph leaks.

However, there were no statistically signiﬁcant differences

in early and long-term mortality, freedom from amputation

and freedom from revision procedures. In this study, older

patients with cardio-respiratory co-morbidities were more

likely to be selected for percutaneous treatment, while

patients with more extensive occlusive disease and those

presenting with acute limb ischaemia were more often

treated with open surgery. The authors concluded long-term

outcomes were similar, even if surgical morbidity was

higher, and both treatment options were considered viable

alternatives.

So what should we tell our patients? The fact is that

the literature regarding surgery or iliac intervention still

remains controversial.

For this reason, a Trans-Atlantic Inter-Society Consensus

(TASC) working group looked at all the available evidence

and published a document on the management of peripheral

arterial disease in 2000. This has subsequently been updated

in 2007 (TASC II Norgren et al. 2007). The TASC II group

represents a consensus between sixteen international

medical and surgical vascular, interventional radiology and

cardiology societies in Europe, North America, Asia, South

Africa and Australia. The TASC document graded evidence

made recommendations according to the US Agency for

Healthcare Policy and Research Guidance for identifying

levels of evidence. The document deals separately with the

recognised vascular segments but also with intermittent

claudication, chronic limb ischaemia and acute limb

ischaemia. It points out that intermittent claudication is by

and large a benign condition with fewer than 2% of patients

ever requiring an amputation. The evidence suggests that

the best predictor of this is an ankle brachial index at pre-

sentation of less than 0.5. Intervention for intermittent

claudication should therefore be conﬁned to patients with

severe lifestyle-limiting disease particularly affecting ability

to work.

The acute and critical limb ischaemia situation is clearly

different and where aortoiliac disease contributes to the

condition it needs to be treated. The TASC document then

goes on to classify disease at different segments. In rec-

ommendation 36, aortoiliac disease is classiﬁed into four

types, A–D (Fig. 1). The TASC document considers that the

available evidence is consistent with endovascular treat-

ment for type A lesions and open surgical treatment for type

D lesions. TASC II considers endovascular treatment to be

the preferred treatment for type B lesions and surgery is the

preferred treatment for good-risk patients with type C

lesions. It is advised that the patient’s co-morbidities,

informed patient preference and the local operator’s long-

term success rates are considered when making treatment

recommendations for type B and type C lesions.

It should be emphasised that while the TASC guide-

lines represent a broad international consensus of expert

societies, the stated level of evidence for aortoiliac

lesions is grade C, i.e. this is a consensus opinion with no

applicable studies of good quality, and there remains

controversy regarding treatment, particularly for advanced

(i.e. TASC type C and D) aortoiliac lesions with endo-

vascular treatment now ﬁrmly established as the treatment

of choice for relatively simple (TASC type A and B)

aortoiliac lesions.

There is now a growing body of contemporary litera-

ture advocating the use of an endovascular-ﬁrst strategy

for all aortoiliac lesions. A retrospective, single-centre

comparison of endovascular therapy versus open surgical

reconstruction for severe aortoiliac occlusive disease,

deﬁned as patients with native complete aortic or iliac

occlusion, has been performed by Kashyap et al. (2008).

Over the six-year study period, patients chosen for surgical

treatment were younger and more commonly were smok-

ers or had hyperlipidaemia. The patient groups were

otherwise well matched with no signiﬁcant difference in

anatomical or symptomatic severity of lesions. Primary

patency rates were lower for patients treated endovascu-

larly but all long-term measures, at three years, including

secondary patency, limb salvage and survival rates were

similar to patients undergoing surgery.

More recently, Jongkind et al. (2010) have published a

meta-analysis of 19 clinical studies, including 1711 patients,

reporting on the endovascular treatment of extensive aorto-

iliac occlusive disease (TASC C and D), which by TASC II

criteria would be treated preferably by surgery. Technical

endovascular success was obtained in 86–100% of cases and

clinical symptoms improved in83–100%. Reported mortality

rates were 0% in 12 of the 19 studies and in the remainder

ranged from 1.2 to 6.7%. Complications ranged from 3 to

45%, with the majority being technical such as access-site

haematomas, pseudoaneurysms, iliac artery injury and distal

embolisation which were most commonly treated with per-

cutaneous or non-invasive techniques. Primary patency rate

for these complex lesions ranged from 70 to 97% at one year

and 60–86% at 4 or 5 years. While the long-term primary

patency rates do not compare favourably with open surgery,

endovascular re-interventions were performed successfully

in the majority of patients achieving very good endovascular

secondary patency rates of 88–100% at one year and80–98%

at 4 or 5 years.

The treatment of complex (TASC C and D) occlusive

iliac lesions can therefore be considered within the remit of

contemporary endovascular therapy and some consider

TASC II to be outdated already, particularly as surgical

options remain available if comparatively lower risk

Aortoiliac Intervention 55

https://t.me/med1917

endovascular therapy fails (Fig. 2a–c). However, as out-

lined in TASC II, consideration should be given to speciﬁc

factors such as patient co-morbidities, informed patient

preference and the local operator’s expertise and long-term

success rates when deciding on the most suitable choice of

treatment for individual patients.

Fig. 1 TASC II recommendations in the treatment of aortoiliac disease (TASC II Norgren et al. 2007)

56 R. Patel and A. A. Nicholson

https://t.me/med1917

2.2 When Is a Lesion Significant?

Before looking at the evidence for angioplasty or stent, it

is important to decide which lesions should be treated.

Aortoiliac intervention should only take place in the clinical

scenarios discussed above (i.e. lifestyle-limiting claudica-

tion, acute and critical limb ischaemia) and where there is a

lesion likely to compromise blood ﬂow thereby contributing

to the patient’s clinical symptoms. A number of clinical

assessments and imaging modalities will provide detailed

and precise information about the morphology of the

aortoiliac segment, and have been described in detail in

‘‘ Assessment of Peripheral Vascular Disease’’. With regard

to angiography the haemodynamic signiﬁcance is usually

measured by assessing the degree of narrowing it produces.

Secondary signs such as asymmetric ﬂow on the side in

question, extensive collaterals and ﬂow defects can give

further information. However, there is intra- and inter-

observer variability in the estimation of the degree of

stenosis present when that estimation is based on diameter

measurements. In one trial measurements based on angi-

ography alone were found to be only 45% sensitive and

63% speciﬁc (Kaufman et al. 1982). Intravascular ultra-

sound can give better measurements of cross-sectional area

of stenoses but is expensive and not widely available. The

measurement of a pressure gradient across a stenosis at

the time of angiography should in theory give precise

information about the signiﬁcance of stenotic disease.

However, there is no consensus in the literature regarding

what constitutes a signiﬁcant gradient (Nemceka and Bhave

2000). Kamphius et al. (1999) found that by using all the

suggestions from the available interventional literature

on the signiﬁcance of gradients they would have stented

anything between 4 and 87% of their patients, emphasising

the overall lack of consensus. They suggested that a mean

gradient of 10 mm Hg at rest or after vasodilation should be

used as a marker of signiﬁcance and this is generally

accepted, though there is no evidence at all for this. Because

some stenoses become more signiﬁcant at higher ﬂow rates

and attenuate the higher frequency components of pressure

waveforms many believe that the systolic pressure is the

most sensitive measure of a signiﬁcant stenosis. Others

argue that peripheral resistance is far more important and

that a mean pressure gradient is more closely related to this

than a systolic gradient and is therefore more physiological.

Peripheral resistance can of course be decreased in order to

mimic limb exercise with the use of vasodilators but there is

no consensus on which vasodilator or dose, nor at what time

a gradient should be measured in relation to the drug

administration. There are in addition many technical factors

that can cause false readings. These include bubbles in the

transducer, the diameter of the catheter in comparison to the

diameter of the stenosis and whether the catheter has end

holes or side holes. In addition, simultaneous pressure mea-

surements allow direct comparison of pressure waveforms

proximal and distal to a stenosis, while pull-back pressure

measurement offers the advantage of a single transducer and

lower proﬁle or unilateral vascular access but is subject to

beat-to-beat variations in blood pressure. In reality most

practitioners assess thepulses andtheanatomical information

provided by the angiogram. Pressures are often reserved to

check post-intervention gradients but when performed pre-

intervention a mean gradient of over 5 mm Hg is accepted if

all the other features point to signiﬁcance. The TASC II

guidelines suggest that in a situation where a stenosis is

of questionable haemodynamic signiﬁcance, pressure mea-

surements may be made to determine its signiﬁcance with

the criteria of peak systolic difference of 5–10 mm Hg

pre-vasodilatation and 10–15 mm Hg post-vasodilatation,

although again there is no evidence base for these criteria.

Fig. 2 TASC type D lesion, infrarenal aortoiliac occlusion (a) and (b), treated by primary stenting of the aorta and common iliac arteries (c)

Aortoiliac Intervention 57

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2.3 Angioplasty or Stent?

There is little data and therefore much uncertainty about the

role of stents compared with angioplasty alone, particularly

for patients with focal aortoiliac stenoses. However, early

aortoiliac angioplasty had a high rate of embolic compli-

cations, particularly when dealing with occlusive rather than

stenotic disease. Indeed many vascular radiologists felt that

iliac occlusions should not be dealt with percutaneously

because of an embolic complication rate of up to 47%

(Ring 1982). The introduction of aortoiliac stenting was a

response to this, patency improvement being a secondary

consideration. It could therefore be argued that the RCT is

unethical in aortoiliac occlusive disease. Nevertheless

RCT’s have been performed, although usually on a mixture

of occlusive and stenotic disease with very dubious

methodology. One such study demonstrated 4-year patency

rates of91.6% for stentsand 74.3% forangioplasty alone,but

the results have never been fully published (Richter 1989).

There is only one peer reviewed published randomized

clinical trial that compares primary stent placement with

PTA followed by stent placement if needed in the iliac

arteries. The Dutch Iliac Stent Trial (DIST) (Tetteroo et al.

1998) enrolled 279 patients with lifestyle-limiting intermit-

tent claudication caused by iliac artery stenosis or occlusion,

and randomized them into two similar groups. Subjects

assigned to group I received primary Palmaz (Cordis Corp,

Miami, FL) stent placement foriliac disease; those in groupII

were treated with angioplasty, withstents reservedfor patients

with suboptimal angioplasty results as judged by a residual

pressure gradient in excess of 10 mm Hg. Patients were to be

assessed with interviews, treadmill studies and sonography 3,

12 and 24 months after treatment. The authors reported that

43% of patients whowere randomized to angioplasty received

iliacstents and that2-year cumulative patency rates forthe two

groups were similar at 71 versus 70%. The authors concluded

thatbecause angioplasty followed byselective stent placement

is less expensive than primary stent placement, the former

should be the treatment of choice for lifestyle-limiting inter-

mittent claudication caused by iliac artery occlusive disease.

However, only 29 iliac artery occlusions were treated

among 279 patients, and by study design, patients with

occlusions more than 5 cm in length were ineligible for

enrolment. Even with such a strict length criterion for eligi-

bility, 10 of the 12 subjects (83%) with occlusions failed

angioplasty alone. Although stents seem to offer special ben-

eﬁts in the treatment of longer segment and occlusive lesions

(Vorwerket al. 1995),little guidanceabout suchpatients (who

might constitute 35–40% ofthose withaortoiliac insufﬁciency

in one’s practice) is therefore provided by this trial.

Furthermore, most patients in the DIST study had mild

clinical symptoms, and only 22% of patients in each

group were classiﬁed as having Society for Vascular

Surgery/International Society for Cardiovascular Surgery

(SVS/ISCVS) grades 3–5 ischemia. Only 10% of patients

had diabetes, and only 10% had simultaneous iliac artery

disease and occlusion of the ipsilateral superﬁcial femoral

artery. The mean pre-treatment resting ankle brachial

index in both groups was 0.77. As a consequence, the

milder pattern of atherosclerotic disease observed in the

DIST study differed from that encountered in many

interventional practices.

In addition the study was designed to have a 90% like-

lihood of detecting a 10% difference in post-treatment

arterial patency after 12 months between the two groups

(power = 90%). Unfortunately, because of inadequate

recruitment and funding, the trial was terminated after less

than 80%of the intended samplehad been enrolled.Outcome

information after as little as 1 year is available in the original

published report for about 60% of subjects who ultimately

enrolled, a fraction that actually represents less than 45% of

the intended patient sample. Thus, even though the authors

did notobserve ‘‘substantialdifferences’’ inclinical outcomes

between their experimental groups, the DIST study was more

likely to miss than to detect the same potential 10%

improvement in 12 month patency rates that were used to

conﬁgure the trial as the actual power was less than 50%.

Because of under-recruitment, the authors attempted to

amplify their sample by reporting the number of lesions

treated, rather than the number of subjects actually

involved. For example, a patient with simultaneous com-

mon and external iliac stenoses or occlusions was classiﬁed

as two treated lesions, rather than as a single person. As a

result, little information about crucial patient subgroups

(e.g., occlusions vs. stenoses, common iliac vs. external

iliac lesions) can be gleaned from this report. Despite the

aforementioned problems, the authors continued to publish

from the original cohort dataset, reporting patency rates and

patient survival at up to 6–8 years with reportedly better

long-term symptomatic success in the selectively stented

group compared to primary stenting but no difference in

iliac patency, ABPI, or quality of life measures between the

two groups. (Klein et al. 2006).

Preliminary results have recently been presented from a

multicentre randomised prospective trial of angioplasty

versus stenting in iliac occlusions (Goode et al. 2010). One

hundred and eighteen patients with iliac occlusions less then

8 cm in length were randomised to either angioplasty

(n = 61) or angioplasty and stent insertion (n = 57). If

angioplasty resulted in any antegrade ﬂow, irrespective of

residual pressure gradient, then a stent was not placed. The

presented results show signiﬁcantly increased complications

(15 vs. 4%) and an increased primary failure rate (24 vs.

5.3%) in the angioplasty group compared to the primary

58 R. Patel and A. A. Nicholson

https://t.me/med1917

stenting group, respectively. There was also a signiﬁcantly

higher residual pressure gradientin the angioplasty versus the

stent group, but interestingly there was no signiﬁcant differ-

ence in residual gradient at two years despite no further

intervention and also no signiﬁcant difference in clinical

outcomes between the two groups at two years. The validity

and applicability of these results will of course depend on the

power of the study, as well as the case mix and sub-group

analyseswithinit, and untilthe full publication we arenot able

to comment. However, fromthe preliminary datait appearswe

are brought back to the original premise that there are sig-

niﬁcantly fewer complications following primary stenting of

iliac occlusions but that stents confer no inherent beneﬁts in

terms of long-term patency as long as we accept the concept

that when PTA alone fails, secondary stenting is indicated.

As previously stated, it would be wrong to ignore

observational data when considering the evidence.

A meta-analysis of such studies has been performed (Bosch

and Hunink 1997). This found a better technical success rate

for stenting (97%) rather than angioplasty (91%) p \0.05.

It also found better overall 4-year primary patency for iliac

stents in critical limb ischaemia (67 vs. 35%), though this is

not the case for claudicants (77 vs. 65%). This emphasises

the need for signiﬁcant sub-group analysis in any study.

A cost effectiveness analysis (Bosch 1998) of aortoiliac

stenotic disease suggested that PTA and selective stent

insertion for suboptimal results is the most cost effective

option but did not deal speciﬁcally with technically more

difﬁcult and potentially complicated occlusive disease.

In a recent meta-analysis of studies for advanced aorto-

iliac occlusive disease (Jongkind et al. 2010), the authors

observed that primary stenting was the most frequently

preferred option. Arguments in favour of primary stenting

in the majority of studies analysed were that this strategy

would reduce the risk of distal embolism and also the risk of

vessel rupture. Three of the studies analysed in this meta-

analysis examined the inﬂuence of stent placement on long-

term patency. Two studies (Pifaretti et al. 2007; Domanin

et al. 2005) found no statistically signiﬁcant difference in

primary patency between patients receiving stents or treated

by balloon angioplasty alone. In contrast, Sixt et al. (2008)

found that the 1-year primary patency rate after stenting

was signiﬁcantly improved compared to balloon angioplasty

alone, 90 versus 70%, respectively.

2.4 What Conclusions Can We Draw

from the Evidence?

As shown there is conﬂicting and confusing evidence

available. Conclusions are difﬁcult to draw but for the

majority of patients the following four guiding priniples are

recommended:

We should defer to the TASC II recommendations most

of the time, with endovascular therapy being the treatment

of choice for type A lesions and the preferred treatment for

type B lesions.

A case for an endovascular strategy ﬁrst for all patients

can be made and is achievable. However, consideration

should be given to the clinical state of the patient, patient

preference, individual operator expertise and long-term

success rates when justifying endovascular or open surgical

treatment.

Aortoiliac stenoses should be angioplastied, reserving

stents for residual gradients greater than 10 mm Hg after

vasodilators or to treat local complications.

Aortoiliac occlusions are best stented to reduce compli-

cation rates.

3 Technical Aspects

The femoral pulse isoften weakor absent inaortoiliac disease.

The quickest and simplest way of accessing a femoral artery

underthese circumstances isby direct palpation inthin patients

(bearing in mind anatomical landmarks) or visualisation of

common femoral calciﬁcation under ﬂuoroscopy and direct

puncture. Ultrasound isalso usefulbut lengthens thetime taken

to puncture. Although ultrasound can be difﬁcult in obese

patients, it can be helpful where the artery is impalpable

(see ‘‘SitesofArterialAccessandtheRoleofClosure

Devices in Percutaneous Arterial Intervention’’). Where

diseaseand symptoms areunilateralit is often betterto perform

angiography from the normal side where the femoral pulse is

good, as iliac stenoses and many iliac occlusions can be

accessed and crossed with a wire from the contralateral side.

Guidewire access across an aortoiliac stenosis is successful in

almost all patients especially if torquable curved hydrophilic

wires are used. Occlusions can often be crossed ipsilaterally

but if this is not possible a subintimal channel can often be

made which is facilitated by access from the contralateral side

using a sidewinder type catheter. Long ﬂexible sheaths can be

very useful for treating lesions from contralateral access sites.

Alternatively, if an iliac lesion is crossed from over the bifur-

cation, and ipsilateral access has already been obtained, the

wire can be snared from the ipsilateral side to achieve an

extremely stable ‘‘through and through’’ wire position and the

lesion can then be treated from either side. Brachial access

should also be considered, particularly when the anatomical

conﬁguration is challenging or has been distorted, such as by

placement of kissing iliac stents or an aortic stent graft and in

bilateral common iliac artery occlusions. Various devices for

recanalisation of chronic total occlusions and re-entry devices

to access the true lumen following sub-intimal passage are

available but are infrequently required. It is important to

administer heparin duringiliac angioplasty or stentinsertionto

Aortoiliac Intervention 59

https://t.me/med1917

prevent pericatheter thrombosis and acute occlusion of the

treatment site. Typically doses of between 3000 and 5000 iu

are used.

3.1 Aortoiliac Stenotic Disease

As indicated above, the evidence suggests that angioplasty

alone should be the procedure of choice in stenotic disease.

A balloon should be used which is suitable to the diameter

and lengthof the lesion. Oversizing is not recommended, as it

leads to pain and possible rupture. Indeed, it is advisable not

to have patients heavily sedated during the balloon inﬂation,

and it is important to titrate balloon inﬂation according to the

patient’s tolerance. Pain isindicative ofadventitial stretching

and may herald arterial rupture. If severe painis experienced,

it isprudent to discontinue ballooninﬂation and toswitch to a

balloon with a smaller diameter.

The end point for aortoiliac revascularization procedures is

determined angiographically or by intra-arterial haemody-

namicmeasurements,whichare readilyobtainedin thisarterial

segment.Ideally,simultaneouswaveformsobtained above and

below the treated segment should overlap, with no mean or

systolic gradient. Generally, most patients have some separa-

tion of the waveforms at peak systole, with a slightly more

rounded peak observed distally. The systolic gradient usually

measuresbetween 1 and3 mm Hg, but themean gradient may

still be zero. Because of the variability in blood pressure over

even short intervals of time, repositioning a single catheter

across a lesionand measuring pressures at differenttimes is an

unreliable way to obtain pressure measurements.

Often, ideal haemodynamic results are not achieved

because of recoil or patient intolerance to balloon inﬂation

to a calibre consistent with elimination of the gradient.

This situation may demand a stent of suitable diameter

and length. Balloon mounted stents are normally preferred

in this situation, although self-expanding stents may be

desirable if the problem is intolerance.

It is important to understand, however, that in critical limb

ischaemia there may be favourable outcomes even when bor-

derline pressure gradients remain after intervention. This is

becausealmost anyhaemodynamicimprovementmay provide

beneﬁts in favour of wound healing or symptomatic relief. In

these patients, such a result is to be preferred over a prolonged

procedure with an increased risk of complications; an emer-

gency surgical procedure is also clearly undesirable. Con-

versely, patients who complain of intermittent claudication

often have mild residual symptoms if a trans-stenotic gradient

of morethan afew millimetresof mercury persists. Injection of

vasodilators to assess results of an intervention can be infor-

mative when borderline results are obtained in patients with

intermittent claudication. A gradient of lessthan 8–10 mm Hg

mean after intra-arterial injection of 0.2 ml of nitro-glycerine

is considered a satisfactory result (Kaufman et al. 1982).

Finally, isolated aortic stenosis should be treated with a

balloon of appropriate diameter as the kissing balloon

technique requires bilateral punctures and the end result is

invariably inadequate because of the ﬁgure of eight shape of

the dilated segment.

3.2 Chronic Iliac Occlusions

As stated above, the chronic iliac occlusion can be crossed

from the ipsilateral or contralateral side(Figs. 3aandb,4a–d).

To avoidembolic complications suchocclusionsshould, in the

Fig. 3 a–b Chronic common

iliac occlusion in a patient with

lifestyle-limiting intermittent

claudication. There is a short

segment of patent artery at the

ostium allowing insertion of a

uni-iliac stent with a good ﬁnal

result

60 R. Patel and A. A. Nicholson

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