Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 31-35

Endovascular management and outcomes of aortoiliac occlusive disease


1 Department of Cardiothoracic and Vascular Surgery, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, India
2 Department of Radiodiagnosis, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, India

Date of Submission07-Jan-2021
Date of Decision03-May-2021
Date of Acceptance10-May-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Puneet Garg
Department of Radiodiagnosis, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_5_21

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  Abstract 


Introduction: Aorto-iliac Occlusive Disease (AIOD) involves the infra-renal aorta and the iliac arteries. Recent studies advocate endovascular management in TASC C and D lesions also. It involves balloon angioplasty with or without stent deployment.5 The aim of this retrospective study is to evaluate the results of endovascular balloon angioplasty and primary stenting in patients of AIOD. Methods: Twenty-five patients with Aorto-iliac occlusion disease who met the inclusion criteria during 1-year study period were included. Patients with acute thrombosis, abdominal aorta or iliac artery aneurysm and additional common femoral artery occlusion were excluded. The TASC II classification was used to define the characteristics of the lesions. The baseline data, procedural details and follow-up results were analysed. Results: Amongst 25 patients studied, age ranged from 40-75 years. Self-expanding metallic stent was employed in all patients. Technical success following primary stenting was achieved in all patients. Procedural times for TASC-II A, B, C and D lesions were 90+ 30, 110+ 40, 135+35 and 155+ 45 minutes, respectively. During follow-up, the cumulative primary patency rates at 1 month and 6 months were 100%. Cumulative primary patency rates at 1 year were 91.67%. Conclusion: Short- term outcomes of balloon angioplasty and stenting for Aorto-iliac artery occlusions in terms of primary patency rates were excellent.

Keywords: Angioplasty, aortoiliac, patency, stenting


How to cite this article:
Kumar M, Choudhury AR, Garg P, Gupta A, Agarwal Y. Endovascular management and outcomes of aortoiliac occlusive disease. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:31-5

How to cite this URL:
Kumar M, Choudhury AR, Garg P, Gupta A, Agarwal Y. Endovascular management and outcomes of aortoiliac occlusive disease. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Nov 30];8, Suppl S1:31-5. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/31/324945




  Introduction Top


Aortoiliac occlusive disease (AIOD) involves the infrarenal aorta and the iliac arteries. The symptoms of AIOD range from being asymptomatic to critical limb ischemia and gangrene.[1] Although it is difficult to determine the exact prevalence as many people are asymptomatic, estimates of prevalence range from 3.56% to 14% in the general population.[2] AIOD is typically caused by atherosclerosis. Risk factors include diabetes mellitus, hypertension, hyperlipidemia, and tobacco use. Nonmodifiable risk factors include age, family, sex, and race.[3] The initial screening investigation in patients with AIOD is ankle-brachial index (ABI). An ABI of <0.9 establishes the diagnosis of AIOD. ABI is followed up with duplex sonography, computed tomography (CT) angiogram, and/or magnetic resonance angiogram to provide detailed information about the location, extent, and the degree of stenosis/occlusion.[4] Established treatment of Trans-Atlantic Inter-Society Consensus (TASC) A and TASC B type of AIOD is by endovascular route. Recent studies advocate endovascular management in TASC C and D lesions also. It involves balloon angioplasty with or without stent deployment.[5] The aim of this retrospective study is to evaluate the results of endovascular balloon angioplasty and primary stenting in patients of AIOD.


  Materials and Methods Top


The retrospective study was conducted by the department of cardiothoracic and vascular surgery and interventional radiology after institutional ethical approval. The data of all patients who had AIOD during 1 year study period were retrieved. Patients with acute thrombosis, abdominal aorta, or iliac artery aneurysm and additional common femoral artery (CFA) occlusion were excluded. The TASC II classification was used to define the characteristics of the lesions. The demographic details, risk factors, comorbidities, symptoms according to Rutherford classification, location of occlusion, TASC lesion, number of stents deployed, occlusion length, stent diameter, and complications such as bleeding, infection, access site pseudoaneurysm, stent occlusion, and death were recorded. The preoperative assessment involved clinical history and examination, ABI recording, and duplex ultrasonography. All of the patients had normal renal function status and then underwent CT angiography to evaluate the lesion characteristics. Stenting was performed under angiographic suite by the same interventional radiologist. Under local anesthesia, arterial access was established through an ipsilateral or a contralateral CFA with a 6-French arterial access sheath depending on the clinical situation [Figure 1]. Occlusions or stenoses were navigated using a 0.035” hydrophilic guidewire [Figure 2]. Perioperatively, heparin 5000 IU was administered through intravenous route. Balloon angioplasty followed by deployment of self-expanding metallic stent was done in all patients. Immediate postprocedural check angiogram was performed to assess the stent patency and distal flow [Figure 3].
Figure 1: Left common iliac angiogram showing focal stenosis of left common iliac artery

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Figure 2: Hydrophilic guidewire of 0.035” passed through stenosed segment followed by balloon angioplasty

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Figure 3: Postcheck angiogram showing patent stent of size 60 mm × 10 mm with good opacification of left common iliac artery

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Technical success was defined as residual stenosis <30% on final intraoperative arteriography.[6] Immediately postintervention, the patients also underwent duplex ultrasonography of the ipsilateral CFA and resting ABI evaluation. The presence of triphasic flow in the CFA and increase in resting ABI from the baseline preoperative value by >0.15 were also considered to be markers of successful procedure. Postintervention, patients received dual-antiplatelet therapy for 3 months and then remained on aspirin lifelong. Patients were followed up with clinical examination and duplex ultrasonography at 1, 6, and 12 months postprocedure. Normal triphasic arterial flow, without high resistance, in the ipsilateral CFA was considered as a marker of stent patency [Figure 4]. In-stent restenosis or failure of primary patency was defined by presentation with clinical symptoms severe enough to warrant reintervention (claudication or chronic limb ischemia as evidenced by embolization, rest pain, or gangrene) or a decrease in ABI of 0.15.[7]
Figure 4: Color and spectral Doppler ultrasound showing triphasic flow in left femoral artery

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The primary outcome of this study was primary patency rates and all-cause mortality. The secondary outcome involved complications such as bleeding, infection, embolization, and access site pseudoaneurysm.

Statistical analysis

The presentation of the categorical variables was done in the form of number and percentage (%). On the other hand, the presentation of the continuous variables was done as mean ± standard deviation and median values. The data entry was done in the Microsoft EXCEL spreadsheet and the final analysis was done with the use of Statistical Package for Social Sciences (SPSS) software version 21.0. (International Business Machines corporation, IBM, Chicago, USA).


  Results Top


Among 25 patients studied, age ranged from 40 to 75 years. The male-to-female ratio was 5.2:1. The patient characteristics are shown in [Table 1]. Lesion and procedural characteristics are listed in [Table 2]. The arterial segment occlusion ranged from 1.4 to 14 cm. Majority of the patients had left iliac artery occlusion [Figure 1]. Occlusion length was longest in TASC D and then TASC C and smallest in case of TASC A. Self-expanding metallic stent was deployed in all patients. Technical success following primary stenting was achieved in all patients. Procedural times for TASC II A, B, C, and D lesions were 90 ± 30, 110 ± 40, 135 ± 35, and 155 ± 45 min, respectively. One patient had undergone surgical bilateral aortoiliac graft placement for distal part of the aorta and both CIA occlusions. The right side graft underwent occlusion, and the stent was deployed in the occluded graft. The number of implanted stents was higher in TASC C and TASC D lesions compared with TASC A and TASC B lesions. Two stents were implanted in each of the three (75%) patients of TASC D lesion and three (33.33%) of TASC C lesion. Two patients with distal embolization were corrected by embolectomy with Fogarty catheter. A patient with access site pseudoaneurysm was treated successfully with manual compression under duplex ultrasound. There was no perioperative mortality. After 6 months, one patient died due to stroke. During follow-up, the cumulative primary patency rates at 1 month and 6 months were 100%. Cumulative primary patency rates at 1 year were 91.67%. There was in-stent restenosis in two patients and one of the patients passed away due to stroke, thus the limb salvage rate of the study at the end of 1 year was 88%. Only two patients in the study developed in stent restenosis followed by lower limb gangrene and hence, underwent below knee amputation. All the patients with patent stent had symptomatic clinical improvement.
Table 1: Distribution of baseline characteristics of study participants

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Table 2: Lesion and procedural characteristics of study participants

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  Discussion Top


The cumulative primary patency rate at 1 year was 91.67% and the limb salvage rate of 88%. Similar results were observed by Cvetic et al. in their prospective study on 100 patients of iliac occlusive disease.[8] In a study by Soga et al., the primary iliac stent patency was 92.5% at 1 year.[9] In a recent large-scale prospective multicenter trial BRAVISSIMO, the authors have revealed the primary stent patency rates at 12 months to be 93.1% for the total patient population treated for TASC A, B, C, and D aortoiliac lesions.[10]

In our study population, technical success was achieved in 100% of all TASC subtypes. Various studies had reported similar results.[11],[12],[13] Conversely, in certain studies, technical success rate varied between TASC II subtypes, as TASC A (91.6%–96.9%) has higher and TASC D has lower rates (71.4%–91.6%).[14],[15],[16] This variation might be due to varied patient profile.

AbuRahma et al. in their retrospective analysis of 149 iliac lesions demonstrated that overall early clinical success was more in the primary stenting group as compared to secondary stenting group. They also advocated that primary stenting should be offered in all the patients with TASC C and TASC D lesions.[17] Yuan et al. in their study[18] reported performing predilatation followed by stenting in most of their patients. The risk of distal embolization following predilatation and stenting in chronic occlusive plaques is minimal. Due to predilatation, the middle and the distal third of the iliac artery did not require stenting, which reduced the length of the stent deployed.

As all of our patients had chronic limb ischemia due to chronic atherosclerosis and not acute thrombosis, predilatation followed by stenting was our preferred mode of treatment. In our study, balloon angioplasty followed by routine stenting was performed in all the cases. In view of increased cost of two sittings in a selective secondary stenting, all the patients were treated with stent, following balloon angioplasty in one sitting only.

Several studies have shown that primary stenting is to be preferred in extensive iliac artery occlusions as it offered the advantage in terms of reduced risk of artery rupture and decreased risk of distal embolization.[19],[20] In our cohort, however, two of the patients developed distal embolization, likely due to some acute thrombotic components in the chronic atherosclerotic plaques. The emboli were taken care of by Fogarty catheter. In all the cases, intraprocedure routine suctioning was done to suction out any thrombus, if any.

The periprocedural complications were very few in our study and were successfully managed. Complication rates reported in other studies ranged between 10% and 24%.[20],[21],[22] In this study, assessment of treatment effectiveness during follow-up was done by clinical examination and Doppler ultrasonography [Figure 4]. According to the recent ACC/AHA guidelines, duplex ultrasound is “reasonable for routine surveillance after endovascular procedures”.[4] The unquestionable advantages of Doppler ultrasound are noninvasiveness, low cost, wide availability, and lack of ionizing radiation. Duplex USG was done at 1-, 6-, and 12-month intervals – triphasic waveform in the ipsilateral SFA was considered a marker of stent patency. Self-expanding metallic stents made of nitinol were used in our study; the median stent diameter was 10 mm. The length of the stent used in most of the procedures was about 20% more than the length of occlusion.

Two of our patients underwent in-stent restenosis and presented with gangrene of the limbs following the procedure. On history taking, it was found that the patients were not compliant with their antiplatelet drugs because of poor socioeconomic status and logistical issues. Noncompliance with antiplatelets was the probable cause of their in-stent restenosis.

Various risk factors and comorbidities such as diabetes, hypertension, hyperlipidaemia, ischemic heart disease, and smoking are associated with peripheral artery disease.[14] In our study, all the patients suffered with at least one of these, most common being smoking. Humphries et al.[23] reported hypertension and hyperlipidaemia were the most common comorbidities in their study of 162 patients of aorto-iliac occlusive disease. Kudo et al. identified smoking and hypertension were dominant risk factors in their 11-year experience of iliac angioplasty and selective stenting.[24] The difference in prevalence may be attributed to epidemiological variation between study groups of each study.

Limitations

This was a retrospective study with small sample size. In addition, there was a shortfall of long-term follow-up outcomes. Furthermore, patient selection was highly selective in cases of TASC C and D groups. Most of the patients in TASC C group had unilateral EIA occlusion, extending to CFA origin. More complex lesions were not taken up for endovascular treatment.


  Conclusion Top


Balloon angioplasty and stenting for chronic atherosclerotic iliac artery occlusions offered excellent primary patency rates regardless of the complexity of occlusions defined by TASC II classification. It is also useful in TASC C and D lesions, provided patient selection is proper. Iliac stenting proved to be an effective and safe treatment modality in all types TASC II lesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Rodríguez SP, Sandoval F. Aortoiliac occlusive disease, a silent syndrome BMJ Case Rep 2019;12:e230770.  Back to cited text no. 1
    
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Pissarra A, Donato P, Pereira B, Madaleno R, Candelária I, Costa J, et al. A retrospective study of endovascular management of aortoiliac occlusive disease. Acta Radiol Port 2017;29:7-11.  Back to cited text no. 5
    
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Cvetic V, Sagic D, Koncar I, Kovacevic V, Radmili O, Antonic Z, et al. Endovascular treatment of different types of iliac occlusions-Results from an observational study. PLoS One 2019;14:e0222893.  Back to cited text no. 8
    
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Soga Y, Iida O, Kawasaki D, Yamauchi Y, Suzuki K, Hirano K, et al. Contemporary outcomes after endovascular treatment for aorto-iliac artery disease. Circ J 2012;76:2697-704.  Back to cited text no. 9
    
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Tewksbury R, Taumoepeau L, Cartmill A, Butcher A, Cohen T. Outcomes of covered expandable stents for the treatment of TASC D aorto-iliac occlusive lesions. Vascular 2015;23:630-6.  Back to cited text no. 12
    
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Taurino M, Persiani F, Fantozzi C, Ficarelli R, Rizzo L, Stella N. Trans-atlantic inter-society consensus II C and D iliac lesions can be treated by endovascular and hybrid approach: A single-center experience. Vasc Endovascular Surg 2014;48:123-8.  Back to cited text no. 13
    
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Ratnam L, Raza SA, Horton A, Taylor J, Markose G, Munneke G, et al. Outcome of aortoiliac, femoropopliteal and infrapopliteal endovascular interventions in lesions categorised by TASC classification. Clin Radiol 2012;67:949-54.  Back to cited text no. 14
    
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Ye W, Liu CW, Ricco JB, Mani K, Zeng R, Jiang J. Early and late outcomes of percutaneous treatment of TransAtlantic Inter-Society Consensus class C and D aorto-iliac lesions. J Vasc Surg 2011;53:1728-37.  Back to cited text no. 22
    
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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