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authors’ opinions, be stented although some would disagree

withthis. The techniquerequires theinsertionofa stent priorto

angioplasty (Fig. 3a and b). Self-expanding stents are indi-

cated and in the author’s experience they will always traverse

the chronic occlusion over the guidewire. Once a stent of

appropriate diameter and length has been deployed it can then

be dilated with a suitable sized balloon. If there is a suitable

iliac stump at the ostium, a uni-iliac stent will work well. If

howeverthe occluded iliacarterydoes nothaveastumpand the

aortic lumen tapers smoothly to the occlusion then ‘‘kissing’’

iliac stents may have to be used, even when the contralateral

iliac artery does not have a signiﬁcant stenosis (Dyet et al.

1993). Good primary and secondary patency rates of kissing

stents in the intermediate term, 79.4 and 97.7% at 3 years

(Haulon et al. 2002), and in the long-term, 72 and 88% at

10 years (Houston et al. 2007)havebeenreported.High

primary technical success rates (94%) and primary and

assisted-primary patency rates of 81 and 94% at 4 years

with kissing stents have also been reported (Sharafuddin

et al. 2008). This study also demonstrated that undersizing

between the aortic lumen and the protruding segments of

the crossing stents in the distal aorta was the only signiﬁ-

cant determinant of restenosis and thus suggests the use of

appropriately oversized kissing self-expanding stents to

occupy the maximum diameter of the distal aorta which

may reduce restenosis rates.

Fig. 4 In this case the MRA

does not demonstrate a lead in

segment in this left iliac

occlusion (a). The occlusion is

ﬂush with the origin. It was

crossed from the contralateral

side using a hydrophilic wire and

sidewinder catheter (b). having

captured the wire on the

ipsilateral side two self-

expanding stents were inserted

and clinical result (d)

Aortoiliac Intervention 61

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The external iliac artery is slightly more prone to rupture

than the common iliac artery but responds as well to

stenting as the common iliac artery. Thrombolytic therapy

for chronic iliac occlusions adds cost, requires prolonged

immobilization and hospital stay and carries the risk of

bleeding complications and should therefore be reserved for

acute aortoiliac occlusions (Fig. 5a–c).

4 Complications of Iliac Angioplasty

and Stenting

Complications and deaths do happen during aortoiliac inter-

ventions (Fig. 6). The British Iliac Angioplasty Stent (BIAS)

registry was originally launched by the British Society of

Interventional Radiologists (BSIR) in2001 to setstandards of

practice for interventional radiologists performing iliac

intervention in the UK. It is now used as a point of reference

for audit and patient information. The latest analysis of the

BIAS data was presented in 2008. This report presents data,

including outcomes, for 2233 patients from 37 UK institu-

tions over a period of 43 months between 2005 and 2008.

The overall rates of complications were low, with

only 3.5% having limb and 5.8% systemic complications.

Complications were much higher for in-patients with critical

ischaemia treated as urgent cases, when systemic complica-

tion rates were as high as 18% and limb complications were

4.6%. While the overall procedural complication rates were

low, and the majority ofthese were either observed or treated

percutaneously, it is important to remember there were 5

amputations (0.2%) and 19 unplanned surgical procedures

(0.7%) due to complications of endovascular treatment.

Overall, 1.2% of patients were discharged from hospital with

a deterioration in limb ischaemia or an unexpected amputa-

tion and the30 days mortalityrate was 2%,although only1of

the 42 deaths was described as procedure-related. The

potential limitations of registry data including incomplete

data collection, non-uniformity of reporting and reporting

bias should however not be forgotten.

Complication rates following endovascular intervention in

the published literature also compare favourably with those

following surgery. Total mean complications for angioplasty

and stenting are 10.4 and 12.3%, respectively, with reported

major complication rates of 3.6 and 0.4%, respectively.

(Uberoi and Tsetis 2007). The major complications are pre-

dominantly occlusive and include iliac artery occlusion,

iliofemoral thrombosis, distal embolization, and aortoiliac

dissection. Other complucations described are access-site

haematoma, pseudo-aneurysm, puncture-site infection, stent

infection and myocardial infarction. This emphasises the

importance of peri-procedural heparinization and good tech-

nique particularly at the time of arterial puncture and closure.

4.1 Puncture-Site Complications

Haemorrhage and/or haematoma formation is not only the

most common bleeding complication but is also generally

the most easily recognised. However, it is important to

remember that blood may dissect away from the site

Fig. 5 IVDSA (a) demonstrates aortic occlusion in a 76-year-old

patient causing acute limb ischaemia. The patient was in sinus rhythm

and had no previous cardiac history. An echocardiogram was normal.

It was assumed that the occlusion occurred secondary to aortic plaque

rupture. Following 12 h of thrombolysis the aorta was patent though

clearly diseased (b). The segment was then treated successfully by

stent insertion (c)

62 R. Patel and A. A. Nicholson

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immediately over the arteriotomy and, in the case of retro-

peritoneal extension, massive blood loss can occur without

apparent local abnormality. Because of the lack of visible

manifestations, failure to monitor pulse and blood pressure

may allow critical and potentially fatal blood loss to go

unchecked. A pulsatile mass at the puncture site may herald a

contained leak or pseudoaneurysm, with the main concern

being the potential for rupture and haemorrhage. For small

lesions,careful observation maybe best becausemany of these

lesions will spontaneously close. Ultrasound-guided com-

pression can be used in many cases because it is non-invasive

and uses readily available equipment. However, success

depends signiﬁcantly on whether anticoagulant therapy is

being administered. In those patients who are anticoagulated,

the success rate decreases to 62 from 73%. In addition, this

technique is sometimes limited by the inability to apply ade-

quate compression due to patient discomfort or because of the

wide neckof thepseudoaneurysm. Stent-graftshave beenused

but are costly and not without their own complications.

Percutaneous thrombin injection under ultrasound guidance is

a safe and effective treatment for pseudoaneurysms (Tisi and

Callam 2009), and we would consider this the treatment of

choice for pseudoaneurysms larger than 2 cm in diameter.

(See ‘‘Endovascular Repair of Iliac, Visceral and False

Aneurysms’’ ) .

4.2 Arterial Rupture

One of the most dramatic and (fortunately) infrequent

complications of angioplasty and stenting is arterial rupture.

It is most often an immediate event with dramatic

symptoms and angiographic ﬁndings (Fig. 6a and b).

However, subacute and chronic presentations are also pos-

sible. There are several risk factors for arterial rupture with

steroid therapy being arguably the most commonly recog-

nised. Other conditions that weaken the arterial wall include

the presence of ﬁbromuscular dysplasia, adjacent inﬂam-

matory arterial changes, or infection of the arterial wall.

Mechanical factors also contribute, with overdistention of

the artery by the use of an oversized balloon a commonly

stated concern. However, in most reported cases of rupture,

the authors had thought that the balloon was appropriately

sized. Bursting of the angioplasty balloon may also con-

tribute to arterial rupture. This is caused by a sudden

delivery of a high-pressure jet at a focal point from the hole

in the balloon. In some cases, surgeons operating to repair a

rupture have identiﬁed large, sharp or densely calciﬁed

atherosclerotic plaques that probably sliced through the

arterial wall during balloon inﬂation. Prior mechanical

trauma, such as laser recanalization or balloon thrombec-

tomy, may also predispose to arterial rupture either by

actual perforation or by weakening of the arterial wall.

The most important ﬁrst step in the management of an

arterial rupture is recognition of the problem. This allows

rapid response and control of the situation before excessive

haemorrhaging occurs. Often, when rupture occurs during

angioplasty, the patient experiences severe pain. Reinﬂation

of the angioplasty balloon to tamponade the leak often leads

to immediate relief of the pain.Insome cases pain also causes

immediate systemic symptoms, such as bradycardia, dia-

phoresis and/or decreased level of consciousness. Unfortu-

nately, one cannot rely on such dramatic symptoms as an

indication rupture. Cases of rupture have occurred in the

Fig. 6 A check angiogram after

left iliac stent insertion clearly

demonstrates contrast

extravasation indicating a

ruptured artery (a). The patient

rapidly became hypotensive but

was stabilised with an occlusion

angioplasty baloon and

intravenous ﬂuids. A stent graft

was then inserted to seal the

rupture (b) and there were no

signiﬁcant sequelae

Aortoiliac Intervention 63

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absence of pain or other symptoms. Thus, it is very important

always to perform an arteriogram immediately after angio-

plasty while maintaining wire access across the treated lesion.

Gross extravasation of contrast is generally seen in cases of

frank rupture. A secondary ﬂuoroscopic sign is medial dis-

placement and effacement of a contrast-ﬁlled bladder sec-

ondary to mass effect from the retroperitoneal haemorrhage.

Once an arterial rupture is recognised, rapid action is

required to prevent death. Maintaining a wire across an

angioplasty site until the result has been assessed is vital.

Having a wire past the disruption allows the operator to gain

immediate control ofthe situation.Tamponade ofthe leakcan

usually be easily achieved by inﬂating a balloon across the

area of rupture, most often the same balloonthat was used for

angioplasty. However, one should not assume that this same-

sized balloon will sufﬁce. Thus, arteriography should be

performed both proximally and distally to the rupture to

ensure tamponade. Because patients may have hypotension

or bradycardia, the operator must also attend to resuscitation

with intravenous ﬂuids and/or atropine as needed.

Once the haemorrhage is controlled and the patient has

been resuscitated, attention can be turned to deﬁnitive

therapy. In the past ruptures were managed surgically with

either patching of the vessel or with ligation and bypass.

However, balloon tamponade described above may also

provide deﬁnitive treatment, albeit with the risk of thrombus

formation and embolisation. In the modern era of endo-

vascular therapy, the most elegant potential solution to

arterial rupture is endovascular stent grafting. Obviously,

for this to be a viable option, one must have an endovas-

cular graft readily available. An alternative to stent grafting

is the deployment of a bare metallic stent. This probably

works by compressing the arterial wall layers against each

other thus sealing the leak. One must remember, however,

that several cases of arterial rupture have reportedly

occurred during primary stent deployment. Having graft

material as an impermeable barrier to cover the arterial

defect would certainly seem to be preferable to the use of a

bare metal stent. Although arterial rupture might seem to be

a catastrophic event, almost all of the reported cases have

been successfully managed without loss of life or limb.

4.3 Embolization

Embolization occurs more frequently than we think.

A Doppler probe placed on a common femoral artery during

iliac intervention will conﬁrm this. However, clinically sig-

niﬁcant embolic events occur in only 3–7% of patients (Dyet

et al. 1997). Emboli can consist of atherosclerotic plaque,

thrombus or cholesterol. The nature of theemboli determines

the success of the different therapeutic options. Local

thrombolytic infusion, which is a mainstay of treating distal

emboli, works poorly if the embolus contains solid material

such as plaque. Percutaneous aspiration thrombectomy is a

good technique for either thrombus or plaque. It requires a

non-tapered catheter with a large end hole (Fig. 7a–d).

Occasionally large emboli have to be surgically removed.

Lesion type is a risk factor with signiﬁcant embolic events

occurring in iliac occlusions more frequently than with

stenoses (Ring 1982). In one series embolization occurred in

9% (6 of 66) of patients with iliac occlusion but in only 0.9%

(2 of 223) of patients with stenoses (Strecker et al. 1996).

Some authorsthink that therisk ofembolization relatesto how

the stent procedure is performed. This author’s published

experience (Dyet et al. 1997) was of ﬁve episodes of embo-

lizationout of72 iliacocclusions (6.9%)that weretreated with

stenting. All occurred during balloon dilatation before stent

deployment. Based on this experience, secondary dilatation

after deployment of a self-expanding stent is considered the

techniqueofchoice. However, primary stentdeployment does

not completely eliminate the risk of embolization.

4.4 Stent-Related Complications

Device-related problems such as failure to deploy or mis-

placement are increasingly rare and beyond the scope of this

chapter. Stent infection is an extremely serious complication

that carriesa signiﬁcantrisk ofmorbidity andmortality, andis

rare. However, infection does occur sporadically. It has been

speculated that the incidence of stent infection is probably

signiﬁcantly underreported because few clinicians suspect

that arterial stents can become infected.

Although the cause for stent infection is sometimes

obscure, a number of factors have been implicated. These

include multiple catheterizations of the same groin site,

increased procedural time and local haematoma formation.

Temporally remote events that lead to bacteraemia can also

lead to stent infection.

The presentation of stent infection is variable. Acute stent

infection can be seen as quickly as 2 days after implantation,

whereassome patientswith remoteor secondarystent infection

have presented yearsafter theinitial procedure. Pain,fever and

white blood cell count elevation are common, although some

patients have presented both without fever and with normal

white blood cell count. A pulsatile mass can herald formation

of a pseudoaneurysm. Another manifestation of an infected

stent is septic emboli to the leg. This may appear as a rash or

painful petechiae in the leg or hypogastric region.

Once a patient is suspected of having an infected stent,

management should be aggressive. Antibiotics should be

administered as soon as blood cultures have been obtained.

Staphylococcus aureus is the most common responsible

organism and antibiotic therapy should be tailored to this

bacterium. However, antibiotics alone are probably not

64 R. Patel and A. A. Nicholson

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Fig. 7 A left external iliac

occlusion (a) was treated by

primary angioplasty followed by

stent achieving a good result (b).

However, check angiography

revealed emboli in the calf

arteries (c) which were aspirated

successfully (d)

Aortoiliac Intervention 65

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sufﬁcient. The most common therapeutic strategy has been

resection of the infected segment and surgical bypass.

Fatalities and limb amputations have occurred but given the

large number of stents that have been placed without

infectious sequelae, it is unclear if antibiotics should be

used routinely at the time of implantation.

5 Future Technologies

Excellent short- and long-term results have been reported

with angioplasty and stenting of the iliac arteries and this is

now widely accepted as an attractive alternative to open

surgical revascularisation. However, the Achilles heel of

angioplasty or stenting is myointimal hyperplasia resulting

in re-stenosis and limiting the long-term durability of

endovascular therapy. Newer technologies such as drug

eluting stents, drug eluting balloons and bioabsorbable

stents are being researched to address this and improve

long-term primary patency rates.

Immunosuppressive and cytotoxic drugs, such as

Sirolimus and Paclitaxel, limit neo-intimal growth of vas-

cular smooth muscle cells and when delivered attached to

balloons or stents have been shown to prevent restenosis.

Large meta-analyses of RCT’s performed after coronary

artery interventions have demonstrated reduced restenoses

and re-intervention rates with drug-eluting stents compared

to bare metal stents in coronary artery disease (Roiron et al.

2006). However, the cardiac interventional trials also

demonstrate that much longer term follow up is required to

evaluate speciﬁc safety concerns and complications of drug

eluting devices such as late stent-related thrombosis in the

coronary vessels. Recently reported studies of drug eluting

stents and balloons in patients with peripheral arterial

disease in the femoropopliteal segments have reported

promising short-term results in non-randomised cohorts

(Lammer et al. 2011; Dake 2009; Tepe et al. 2008). Longer

term randomised clinical trials are still awaited.

Bioabsorbable stents offer the attractive theoretical

advantages of leaving no permanent vascular implant,

thought to be a trigger for late restenosis, while maintaining

a temporary scaffold preventing vessel recoil and allowing

for outward vessel remodelling. This has been demonstrated

to be a feasible technology in the peripheral vessels (Bosiers

2009), however its potential clinical efﬁcacy has not yet

been established.

At present, while studies and follow up are already under-

way, the use of drug eluting devices and bioabsorbable stents

in the peripheral vasculature are considered investigational.

Undoubtedly these technologies hold a great deal of potential

andsome promisingclinical datais emerging, butthere isstill a

great dealof furtherresearch and development required before

these technologies become everyday clinical reality.

6 Conclusion

There is a large body of evidence supporting the safety

and efﬁcacy of the endovascular treatment of iliac arterial

lesions under the appropriate clinical circumstances.

Although debate continues, it seems a reasonable strategy to

perform angioplasty for iliac stenosis, employing stents

where angioplasty alone has failed. Iliac occlusions, how-

ever, should be managed by primary stent insertion to avoid

the high risk of distal embolisation. The results of iliac artery

angioplasty or stenting are comparable to those of surgery,

and despite the TASC recommendations, a majority of

surgeons and interventional radiologists seem to favour the

endovascular option wherever possible. Serious complica-

tions are relatively uncommon, but procedures should

always be performed with very careful technique, including

maintaining the guidewire positioned across the lesion until a

satisfactory result has been conﬁrmed. This allows the man-

agement of any complication endovascularly, meaning that it

should only rarely be necessary to resort to surgery.

References

Ballard JL, Burgen JJ, Singh P et al (1998) Aorto iliac stent

deployment vs surgical reconstruction: analysis of outcome and

cost. J Vasc Surg 28:94–101

Benson K, Hartz AJ (2000) A comparison of observational studies and

randomised control trials. NEJM 342:1878–1886

Bosch JL, Hunink MG (1997) Stent or PTA in iliac ‘‘occlusive’’

disease meta-analysis of the results of PTA and stent placement in

aortoiliac occlusive disease. Radiology 204:87–96

Bosch JL (1998) Iliac arterial disease: cost effectiveness analysis of

stent placement vs PTA. Radiology 208:641–681

Bosiers M (2009) Absorbable metal stent implantation for treatment of

below-the-knee critical limb ischemia: 6 month analysis.Cardiovasc

Intervent Radiol 32:424–435

British Society of Interventional Radiology (2001) British Society of

Interventional Radiology iliac angioplasty study (BIAS). Dendrite

Clinical Systems, Oxfordshire

British Society of Interventional Radiology (2008) Third BSIR iliac

angioplasty andstenting report (BIAS 3). DendriteClinical Systems,

Oxfordshire

Burke CR, Henke PK, Hernandez R et al (2010) A contemporary

comparison of aortofemoral bypass and aortoiliac stenting in the

treatment of aortoiliac occlusive disease. Ann Vasc Surg 24:4–13

Concato I, Shah N, Howitz RI (2000) Randomised control trials,

observational studies in the hierarchy of research design. N Engl J

Med 342:1887–1892

Dake M (2009) Interim analysis of two-year results for the Zilver PTX

drug-eluting peripheral stent. CIRSE 2009 ID: 16485

Domanin M, Crippa M, Talarico M et al (2005) Endovascular

treatment of complex atherosclerotic lesions of the aortoiliac

segment. J Vasc Endovasc Surg 12:9–16

Dyet JF, Cook AM, Nicholson AA (1993) Self expanding stents in

iliac arteries. Clin Rad 48:117–119

Dyet JF, Gaines PA, Nicholson AA (1997) Treatment of chronic iliac

occlusions by means of percutaneous endovascular stent placement.

J Vasc Interv Radiol 8:349–353

66 R. Patel and A. A. Nicholson

https://t.me/med1917

Goode SD, Hersey N, Cleveland TJ et al (2010) STAG trial: a

multicentre randomised clinical trial comparing angioplasty and

stenting for the treatment of iliac occlusion. CIRSE 2010 ID: 45804

Haulon S, Mournier-Vehier C, Gaxoyye V et al (2002) Percutaneous

reconstruction of the aortoiliac bifurcation with ‘‘kissing stents’’

technique: long-term follow-up in 106 patients. J Endovasc Ther

9:363–368

Houston JG, Bhat R, Ross R, Stonebridge PA (2007) Long-term results

after placement of aortic bifurcation self-expanding stents: 10 year

mortality, stent restenosis,and distaldisease progression.Cardiovasc

Intervent Radiol 30:42–47

Ioannidis JPA, Haidich AB, Lau J (2001) Any casualties in the clash of

randomised and observational evidence? BMJ 322:8790

Jongkind V, Akkersdijk GJM, Yeung KK et al (2010) A systematic

review of endovascular treatment of extensive aortoiliac occlusive

disease. J Vasc Surg 52:1376–1383

Kamphuis AG, van Engelen AD, Tetteroo E et al (1999) Impact of

different haemodynamic criteria for stent placement after sub

optimal iliac angioplasty. Dutch iliac stent trial study group. J Vasc

Interv Radiol 10:741–746

Kashyap VS, Pavkov ML, Bena JF et al (2008) The management of

severe aortoiliac occlusive disease: endovascular therapy rivals

open reconstruction. J Vasc Surg 48:1451–1457

Kaufman SL, Barth KH, Kadir S et al (1982) Haemodynamic

measurements in the evaluation and follow up of transluminal

angioplasty ofthe iliacand femoralarteries. Radiology 142:329–336

Klein WM, van der Graaf Y, Seegers J et al (2006) Dutch iliac stent

trial: long-term results in patients randomized for primary or

selective stent placement. Radiology 238:734–744

Lammer J, Bosiers M, Zeller T et al (2011) First clinical trial of nitinol

self-expanding everolimus-eluting stent implantation for peripheral

arterial occlusive disease. J Vasc Surg 54:395–401

Lau J, Ioannidis JPA, Schmid CH (1998) Summing up evidence: one

answer is not always enough. Lancet 351:123–127

Nemceka A, Bhave A (2000) Diagnostic evaluation of aorto iliac

occlusive disease: when is a lesion signiﬁcant? Techniques in

vascular and interventional radiology 3:180–185

Piffaretti G, Tozzi M, Lomazzi C et al (2007) Mid-term results of

endovascular reconstruction for aorto-iliac obstructive disease. Int

Angiol 26:18–25

Richter GM (1989) RCT comparing primary iliac stenting and PTA.

In: Stents: state of the art. Polyscience, Morin Heights, 30–35

Ring EJ (1982) Percutaneous recanalisation of common iliac

occlusions: an unacceptable complication rate. Am J Roentgenol

139:587–589

Roiron C, Sanchez P, Bouzamondo A et al (2006) Drug eluting stents:

an updated meta-analysis of randomised controlled trials. Heart

92:641–649

Sharafuddin MJ, Hoballah JJ, Kresowik TF et al (2008) Long-term

outcome following stent reconstruction of the aortic bifurcation and

the role of geometric determinants. Ann Vasc Surg 22:346–357

Sixt S, Alawied AK, Rastan A et al (2008) Acute and long-term

outcome of endovascular therapy for aortoiliac occlusive lesions

stratiﬁed according to the TASC classiﬁcation: a single-center

experience. J Endovasc Ther 15:408–416

Strecker EP, Boos IB, Hagen B (1996) Flexible tantalum stents for the

treatment of iliac artery lesions: long-term patency, complications,

and risk factors. Radiology 199:641–647

TASC Working Group (2000) Management of peripheral arterial

disease (PAD). TransAtlantic Intersociety Consensus (TASC).

J Vasc Surg 31:S1–S296

TASC II Norgren L, Hiatt WR, Dormandy JA et al (2007) Inter-society

consensus for the management of peripheral arterial disease

(TASC II). J Vasc Surg 45:S5–S67

Tepe G, Zeller T, Albrecht T et al (2008) Local delivery of paclitaxel

to inhibit restenosis during angioplasty of the leg. N Engl J Med

358:689–699

Tetteroo E, Haaring C, van der Graaf Y et al (1998) Randomised

comparison of primary stent placement versus primary angioplasty

followed by selective stent placement in patients with iliac-artery

occlusive disease. Lancet 341:1153–1159

Tisi PV, Callam MJ (2009) Treatment for femoral pseudoaneurysms.

Cochrane Database Syst Rev. Apr 15;(2):CD004981

Uberoi R, Tsetis D (2007) Standards for the endovascular management

of aortic occlusive disease. Cardiovasc InterventRadiol 30:814–819

Upchurch GR, Dimick JB, Wainess RM et al (2004) Diffusion of new

technology in health care: the case of aorto-iliac occlusive disease.

Surgery 136:812–818

Vorwerk D, Gunther RW, Schurman K et al (1995) Primary stent

placement for chronic iliac artery occlusions: follow-up results in

103 patients. Radiology 194:745–749

Wolf GL, Wilson SE, Cross AP et al (1993) Surgery or balloon

angioplasty for peripheral vascular disease: a randomised clinical

trial. J Vasc Interv Radiol 4:639–648

Aortoiliac Intervention 67

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Femoropopliteal Arterial Intervention

Stefan Mu

ller-Hu

lsbeck and Heide Preuß

Contents

1 Introduction.......................................................................... 69

2 The History of Interventional Treatment in the SFA .... 70

3 Equipment and Technique ................................................. 70

4 Nitinol Self-Expanding Stents ............................................ 71

4.1 Self-Expanding Stents for Prevention of Restenosis ........... 71

4.2 Drug-Eluting Stents in the SFA............................................ 73

4.3 Mechanical Limitations of Self-Expanding Stents

in the SFA.............................................................................. 74

5 Stent Grafts .......................................................................... 74

6 Drug-Eluting Balloons......................................................... 76

7 Cryoplasty............................................................................. 77

8 Peripheral Cutting Balloon ................................................ 77

9 Brachytherapy...................................................................... 78

10 Conclusion and Future Considerations............................. 78

References...................................................................................... 78

Abstract

Since the publication of the TASC document in 2000 and

the update of TASC II in 2007, several new devices have

been developed which may improve the outcome of

endovascular therapy in the SFA increasing the success

rate and especially reducing the incidence of restenosis.

Therefore the use of endovascular treatment in TASC A,

B and C lesions may become the norm, especially with

the new TASC IIB document, which is currently under

review. This chapter will describe current techniques for

SFA treatment of chronic lesions. The standard requisites

needed will be named in a balanced manner especially

with respect of implants such as stent and stent-grafts. In

order to avoid implants and their potential limitations,

this chapter will be completed by newer treatment

concepts which cannot be stated as state-of-the art

procedures like PTA and stent at the moment. Of these,

DEBs might be one of the top treatment modalities in the

future, if the early promising results are proved by the

many on going trails. In general, interventional treatment

of claudicants replaces more and more classical surgical

techniques.

1 Introduction

With the development of new endovascular techniques

during the past two decades, the treatment of peripheral

arterial disease (PAD) has undergone dramatic changes. In

January 2000, the Trans-Atlantic Inter-Society Consensus

document was published in order to create standardized

guidelines for the management of PAD (TASC 2000). Since

January 2000, a new generation of nitinol self expanding

stents and stent-grafts has become available. In addition,

new techniques such as brachytherapy, cryotherapy, cutting

balloons, atherectomy, and drug-eluting stents as well as

drug-eluting balloons are being used for prevention of

restenosis. These newer devices and techniques were not

S. Müller-Hülsbeck (&)  H. Preuß

Department of Diagnostic and Interventional Radiology/

Neuroradiology, Ev.-Luth. Diakonissenanstalt zu Flensburg,

Zentrum für Gesundheit und Diakonie, Knuthstr. 1,

24939 Flensburg, Germany

e-mail: muehue@diako.de

URL: radiologie.diako.de

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

DOI: 10.1007/174_2012_566, Ó Springer-Verlag Berlin Heidelberg 2012

https://t.me/med1917

included in the TASC 2000 literature summary and rec-

ommendations. Both the guidelines produced by TASC in

2000 and those produced by the ACC/AHA in 2005 are very

long and detailed. To address this issue, the TASC II

guidelines released in 2007 (Norgren et al. 2007a, b, c)

focus on the management of PAD as a result of athero-

sclerosis affecting the legs only. TASC II includes citations

of newer device technology such as brachytherapy and the

use of ﬁrst-generation Sirolimus-eluting stents. Further-

more, they focus on the key aspects of diagnosis and

management and are, therefore, much easier to use, facili-

tating widespread distribution and dissemination of the

guideline recommendations. With the evolution of such new

devices there are new opportunities for endovascular

intervention in the superﬁcial femoral artery (SFA). The

purpose of this review is to summarize different new

approaches, their limitations, current important clinical

trials, and future developments which may change treatment

paradigms.

The basic techniques of intervention in the SFA are well

described in many other texts, and will not be dealt with in

this chapter.

The superﬁcial femoral artery and popliteal artery are

frequently affected by atherosclerotic disease. In the past,

revascularization has been by means of surgical femoro-

popliteal or femorodistal bypass (TASC 2000; Cheng et al.

2001). However, open surgery is more invasive, requires

longer hospitalization, is less successful where distal run-off

is limited, and anticoagulation may be required where there

is an anastomosis below the knee. Therefore, endovascular

procedures have been used with increasing frequency (as

indicated in Norgren et al. 2007b), even for the treatment of

long lesions, including Type C lesions with multiple ste-

noses or occlusions totaling [15 cm with or without heavy

calciﬁcation, recurrent stenoses or occlusions that need

treatment after two endovascular interventions, and even

sometimes Type D lesions with chronic total occlusions of

CFA or SFA ([20 cm in length with or without popliteal

artery involvement), chronic total occlusion of popliteal

artery, and proximal trifurcation vessels.

2 The History of Interventional Treatment

in the SFA

Non-surgical revascularization began in earnest more than

40 years ago in 1964 with percutaneous transluminal

angioplasty (PTA) (Dotter and Judkins 1964). One major

limitation of PTA is the restenosis rate due to early vessel

recoil and neointimal proliferation. Unlike other vascular

beds, the incidence of restenosis in the SFA is very high

(Fig. 1) with restenosis rates of 20–70% being reported

(Duda et al. 2003, 2005). This compares with 6 months,

restenosis rates (deﬁned as stenosis greater than 50%) of

20–35% in the coronary arteries, 15–20% in the renal

artery, and 2–5% in the carotid artery after angioplasty

alone. In the SFA, the technical success and durability

strongly correlate with the lesion morphology, with gener-

ally poorer results after treatment of longer stenoses and/or

occlusions (TASC 2000). Metallic stents have been highly

successful in reducing restenosis rates in territories such as

the coronary and renal arteries. However, no such beneﬁts

were initially demonstrated in the SFA. Patency rates 12

months after the placement of Wallstents (Boston Scientiﬁc,

Natick, Maryland) and Palmaz stents (Cordis, Miami,

Florida) in mostly short SFA lesions have been reported to

range between 22 and 61% (TASC 2000). An evolutional

steps forward was done by using Nitionol-based self-

expanding stents in the SFA for treatment of long-ranging

stenoses and occlusions. Patency rates increased in a range

from 69 to 75% (Norgren et al. 2007b).

3 Equipment and Technique

The SFA can be approached either contralaterally or ipsilat-

erally. Thecontralateral approachinvolvescrossing theaortic

bifurcation, increasing the complexity of the procedure. A

long sheath (45 cm or longer up to 90 cm) placed over the

bifurcation may be of value, and this approach may be par-

ticularly helpful in treating proximal lesions. The ipsilateral

approach is, however, in many ways simpler. An antegrade

puncture of the common femoral artery is performed below

the inguinal ligament. It has the advantages that standard

length guidewires and balloons may be used, and any com-

plications that may occur can be managed relatively easily.

Angioplasty can be carried out using 4 or 5 Fr vascular

sheaths (dependent on the preferred guidewire technology:

0.018

requires 4 Fr only, whereas 0.035

needs at least

5 Fr). If stents are to be used up to 6 or 7 Fr sheaths will be

required (dependent on the stent device and manufacturer:

standard Nitinol stent 4–6 Fr, covered stents 7 Fr). Having

placed a sheath in the vessel the lesion must be crossed. In

the case of stenotic disease this is usually relatively easy,

especially when using 0.018

wire technology with hydro-

philic coated tips (Boston Scientiﬁc, Natick, MA; Terumo,

Tokyo, Japan). However, occlusions may be more difﬁcult

to cross, especially if they are calciﬁed. Here, hydrophilic

guidewires, such as the Terumo 0.035

(Terumo, Tokyo,

Japan) are of immense value and are still standard tools. In

case of occlusive disease, the passage of the guidewire will

often be subintimal, providing high recanalization rates in

total occlusions of more than 85% (range 81–94%, standard

error 2.9%) (London et al. 1994). The technique of subin-

timal angioplasty is not as dependent on length, but rather

on the presence of normal vessel above and below the

70 S. Mu

ller-Hu

lsbeck and H. Preuß

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occlusion to provide initial access to the subintimal plane as

well as a re-entry point (Desgranges et al. 2004).

4 Nitinol Self-Expanding Stents

Nitinol stents have been proposed as a potential solution for

treatment of complex SFA lesions. Modern nitinol stents

exert a constant radial force on the arterial wall and are more

ﬂexible than their predecessors, including balloon expand-

able stents such as the Palmaz. Currently, there are several

nitinol stents designed for use in the femoropopliteal artery

segment available on the market (such as Misago

Termumo, Tokyo, Japan; Absolute

, Abbott Vascular,

Santa Clara, CA; Smart

, Cordis, Bridgewater, NY;

Luminexx

, CR Bard, Tempe, AZ; Sentinol

, Boston

Scientiﬁc, Natick, MA; Lifestent NT

, CR Bard, Tempe,

AZ; SinusSuperﬂex

, Optimed, Ettlingen, Germany and

Zilver

stents, Cook, Bloomington, IN, USA). Despite the

plethora of stents available the principles of construction are

quite similar.The generalstent designconsists ofrepetition of

zigzag units and links which integrate them. The form of

the zigzag or peak to valley design tends to differ as well as

the bridges or transposition zones connecting the zigzag

elements (Müller-Hülsbeck et al. 2010). The clinical results

of the various stent designs may not be the same, as there are

important differences between their designs and surfaces.

Owing to their poor ﬂexibility, balloon expandable stents

can only be used to treat short lesions (Grimm et al. 2001;

Grenacher et al. 2004; Sabeti et al. 2004). Due to this severe

limitation, balloon expandable stents are not applicable in

the femoropopliteal artery segment, and Nitinol-based

stents can be seen as the state-of-the-art implants in the SFA

at the moment.

4.1 Self-Expanding Stents for Prevention

of Restenosis

In a retrospective analysis of primary stenting of 92 limbs in

82 patients with chronic limb ischemia, Mewissen implan-

ted 189 SMART stents (2/limb, lesion length 4–24 cm).

Fig. 1 Digital subtraction angiogram (DSA) of the superﬁcial femoral artery of a patient with claudication. The short occlusion was successfully

dilated (b, c). However, after 6 months, restenosis occurred (d) which correlated with the recurrent limitation of walking distance

Femoropopliteal Arterial Intervention 71

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