Gustavo S. Oderich MDProfessor of SurgeryDirector of Endovascular TherapyDivision of Vascular and Endovascular Surgery
TIPS & TRICKS FOR ILIAC CTO LESIONS
SITE2015
FACULTY DISCLOSURE
• Consulting, CEC/ DSMB fees*Cook Medical Inc., WL Gore
• Research grants*Cook Medical Inc., WL Gore, Atrium Maquet
• Investigational, off-label use of devicesFenestrated, Branched Endografts, Atrium Maquet iCAST
• Speaker fees for non-CME conferences WL Gore, Endologix
* All consulting fees and grants paid to Mayo Clinic
SMA
R renal
L renal
Pre- Post-
• Peri-renal thrombus• Small hypoplastic aorta• Eccentric, cauliflour
calcification• Multiple failed
interventions
- Mortality: 1-4% - 5yr Patency >90%- Morbidity: 20-25%
< 1-5%
ROLE OF OPEN SURGERY
ENDOVASCULAR APPROACH IS WIDELY ACCEPTED FOR TASC D LESIONS
Sixt et al. J Endovasc Ther 2012
ILIAC STENTING
TASC A/BTASC C/D
TECHNICAL CONSIDERATIONS
• Choice of approachFemoral (ipsi/contra)Brachial/ radial
• Hybrid endarterectomy?• Adjuncts
Atherectomy (debulking)Reentrance catheters/IVUS
• Choice of balloons & stentCovered vs bare metal?Balloon vs self-expandable?
• Aortic stenting (CERAB)?
CHOICE OF APPROCH
• Retrograde approach- More convenient, but can be difficult to reentry
• Antegrade approach- Easier reentry, easier to stay central-luminal - Avoids dissections at the aortic bifurcation
• Contralateral femoral (up & over)- Less support but possible
• Brachial or radial- More support but cumbersome
ANTEGRADE UP & OVER APPROACH
V12Pulse t-PAMechanical thrombectomyPTA
Viabahn
V12
5Fr MPAcatheter
7Fr MPA Guide
7Fr Sheath7Fr Raabe sheath
7Fr MPA guide5Fr MPA catheter
HYBRID FEMORAL ENDARTERECTOMY
• Concomitant femoral bifurcation/ profunda disease
• Preference for bovine pericardial patch
• Before or after iliac stenting
Piazza et al. J Vasc Surg 2011
RESULTS OF FEMORAL ENDARTERECTOMY IN TASC D ILIAC LESIONS
ADJUNCTS FOR DIFFICULT ILIAC CTO
• IVUS• Reentrance catheters• Atherectomy
IVUS technology combined with reentry device
Dual channel device with IVUS Chromaflo
IVUS ASSISTED RECANALIZATION
• Percutaneous Right CFA• Left Femoral Endarterectomy• Retrograde left iliac SIA• Reentrance into distal aortic bifurcation• Bilateral Kissing CIA stenting•Left EIA stenting to the CFA
DEBULKING ATHERECTOMY WITH STENTING
BALLOONS & STENTS
• Long Balloons: Start with smaller, than the desired outcome
• Balloon Expandable Stents for Common iliac arteries and calcified external iliac arteries
• Self-Expanding Stents for tortuous external iliac arteries
Undersize
Do not rebuild the aortic bifurcation unnecessarily highSeparate aortic stenting then small overlap of iliac stents
KISSING STENTS
Too High Just right
• Inability to agressively dilate narrow aortic bifurcations
• Difference in stent configuration• Dead space around stents• Turbulence, stasis, re-circulation
around cells of stent and dead space
Neointimal hyperplasia Thrombus formation
J Vasc Interven Radiolo 2000
KISSING STENT FAILURE
CoveredEndovascular ReconstructionAorticBifurcation
Courtesy of Maquet Europe and Michel ReijnenP Goverde, M Reijnen, F Grimme
Adapted from Goverde, LINC 2013
Bare-Metal Stent Covered Stent
NEO AORTIC BIFURCATION
Potential advantages• PTFE layer
- Physical barrier- Less risk of embolization- Less risk of arterial disruption
• Radial force• Precise deployment• Varied configuration• Smaller profile
BALLOON EXPANDABLE COVERED STENT
1 stent = 4 shapes
12mm
20mm
12mm
18mm
16mm
Courtesy of Peter Goverde and Michel Reijnen
COVERED STENTAdvanta V12
Covered iliac stentsRate of binary stenosis
Author, year
Design n Stent type Covered Uncovered
Sabri, 2010 Retrospective 26 covered28 uncovered
Balloon-Expandable
1yr:92%2yr:92%
1yr:78%2yr:62%
Lammer, 2000
Prospective 61 Self-expandable
1yr:91% -
Wiesinger, 2005
Prospective 60 Self-expanding
1yr:91% -
Bosiers, 2007
Prospective 91 Balloon-Expandable
1yr:91%
Chang, 2008
Retrospective 71 covered122 uncovered
Mostly Self-Expandable
5yr:87% 5yr:53%
Mwipatayi,2011
RCT 83 covered84 uncovered
Balloon-Expandable
18mo:92% 18mo:75%
Grimme, 2012
Retrospective 69 primary46 re-intervention
Balloon-Expandable
P 1yr:95%P 2yr:90%R 1yr:88%R 2yr:82%
CONCLUSIONS
• Endovascular approach has been widely accepted as first option in many patients with TASC D iliac lesions
• Brachial approach may be needed in a minority of patients with difficult lesions
• Use of adjuncts (reentrance, atherectomy) may increase technical success
• Covered stents and CERAB needs to be considered to improve patency rates