1. FMRP 2014 | 1 Marc Bosiers Koen Deloose Joren Callaert A.Z. Sint-Blasius, Dendermonde Imelda Hospital, Bonheiden Patrick Peeters Jürgen Verbist OLV Hospital, Aalst Lieven Maene R.Z. Heilig Hart, Tienen Koen Keirse Bart Joos BEC 2014, София Open surgical vs. endovascular treatment of iliac cases Open surgical vs. endovascular treatment of iliac cases Koen Deloose, MD

2. FMRP 2014 | 2 Real life experience…how would you treat… …this TASC A lesion ?

3. FMRP 2014 | 3 Real life experience…how would you treat… …this TASC B lesion ?

4. FMRP 2014 | 4 Real life experience…how would you treat… …this TASC C lesion ?

5. FMRP 2014 | 5 Real life experience…how would you treat… …this TASC D lesion ?

6. FMRP 2014 | 6 Real life experience…, according to TASC II recommendations Tasc D lesionTasc A lesionTasc C lesion SurgeryEndovascular Tasc B lesion

7. FMRP 2014 | 7 Real life experience…, according to my recommendation Tasc D lesion Tasc A lesion Tasc C lesionTasc B lesion Endovascular firstEndovascular

8. FMRP 2014 | Why this personal recommendation…? Invasive nature of aorto- iliac surgery, although extremely durable 8 Equal endovascular patency results also in TASC C & D lesions

9. FMRP 2014 | Why this personal recommendation…? 9 Wound Complications Acute/chronic Renal Failure Cardiac problems Pulmonary complications Spinal cord ischemia Colon ischemia Sexual dysfunction Slovut DP, Lipsitz EP et al : Circulation. 2012; 126: 1127-1138 Invasive nature of aorto- iliac surgery, although extremely durable

10. FMRP 2014 | Why this personal recommendation…? 10 90% @ 2yr 85% @ 5yr De Vries SO, Hunink MG et al. Journal of Vascular Surgery 1997, 26;4:558–569 Invasive nature of aorto- iliac surgery, although extremely durable

11. FMRP 2014 | Why this personal recommendation…? 11 Equal endovascular patency results also in TASC C & D lesions Retrospective, single arm, non-randomized series

12. FMRP 2014 | Why this personal recommendation…? 12 Equal endovascular patency results also in TASC C & D lesions

13. FMRP 2014 | 13 325 inclusions TASC A/BTASC C/D Belgium 140 85 Italy 50 50

14. FMRP 2014 | 12 & 24-month overall primary patency 14 93.1% @ 1 yr 87.9% @ 2 yr

15. FMRP 2014 | 12 & 24-month primary patency 15 TASC ATASC B A | 88.0% B | 88.5% P= 0.516 TASC CTASC D C | 91.9% D | 84.8% TASCbaseline12MFU24MFUtimepoint A13211395patients at risk B585139patients at risk C554335patients at risk D806851patients at risk B | 96.5% A | 94.0% C | 91.3% D | 90.2% P=0.84 12 months24 months

16. FMRP 2014 | 12 & 24-month primary patency 16 Absolute ProOmnilink Eliteboth Absolute Pro 92.1% P=0.058 Omnilink Elite 85.2% Both stents 75.3% Numbers at risk Baseline12MFU24MFU Absolute Pro 147128101 Omnilink Elite 151125103 both 272215 Absolute Pro 96.1% Omnilink Elite 91.8% Both stents 84.4% P=0.84 12 months24 months

17. FMRP 2014 | 17 Univariate regression analysis (Cox proportional harzards model) Multivariable regression analysis Predictors for restenosis at 12 months (patency failure) Obs ParameterProbChiSqHazard Ratio A Kissing Stent (yes vs. no) 0.00123,272 B Obesity (yes vs. No) 0.01092,490 TASC classification nor lesion length was (independently) predictive of restenosis

18. FMRP 2014 | Kissing with conventional stents doesn’t work very well… 18

19. FMRP 2014 | 19 Kissing with conventional stents doesn’t work Geomatrical disturbances Chronical physical irritation Thrombus formation Immature mesenchymal formation Intimal hyperplasia Saker M et al. J Vasc Interv Radiol 2000. 11:333–336.

20. FMRP 2014 | Correct technique for bifurcation lesions… 20 Covered Endovascular Reconstruction Aortic Bifurcation Covered Endovascular Reconstruction Aortic Bifurcation With the courtesy of Peter Goverde, ZNA, Belgium

21. FMRP 2014 | …the reasons to prefer covered stents in aorto-iliac stenting are…. Perforation is not an issue Prevention of distal embolization Avoidance of “nidus” and physical irritation 21 With the courtesy of Peter Goverde, ZNA, Belgium

22. FMRP 2014 | The correct technique : sizing PER-PROCEDURAL QVA-SIZING ! 15 – 15 – (30) RULE (=60) Proximal main stentgraft end Overlap main – side stentgrafts (conical main stentgraft segment) Distal main stentgraft end Aorto-iliac bifurcation 22 15mm 30mm

23. FMRP 2014 | 0.035” supportive wire Long protective sheath 9 F (23 cm) Introduction of the Atrium Advanta V12 – 12 mm 23 The correct technique : main stentgraft introduction With the courtesy of Peter Goverde, ZNA, Belgium

24. FMRP 2014 | Introduction of a XL Latex balloon in the proximal main stentgraft Atrium Advanta V12- 12mm Manual inflation of the XL balloon up to “healthy” proximal aortic sizes : conicalization 24 The correct technique : “Conicalization” With the courtesy of Peter Goverde, ZNA, Belgium

25. FMRP 2014 | 0.035” steerable workhorse wire + supporting catheter Check of intraluminal tract by pigtail catheter Long protective sheaths 7 F (23 cm) 25 The correct technique : Re-pass main stentgraft by second guidewire With the courtesy of Peter Goverde, ZNA, Belgium

26. FMRP 2014 | 0.035” supportive workhorse wires 2 stentgrafts Atrium Advanta V12 > iliac sized 26 The correct technique : positioning of 2 iliac stentgrafts in kissing formation With the courtesy of Peter Goverde, ZNA, Belgium

27. FMRP 2014 | 0.035” supportive workhorse wires 2 stentgrafts Atrium Advanta V12 > iliac sized 27 The correct technique : simultaneous inflation of 2 iliac stentgrafts With the courtesy of Peter Goverde, ZNA, Belgium

28. FMRP 2014 | 28 The correct technique : final result With the courtesy of Peter Goverde, ZNA, Belgium

29. FMRP 2014 | …and it seems to work… – Mwipatayi BP, Thomas S, Wong J et al. A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease (COBEST). J Vasc Surg 2011 – Sabri SS, Choudhri A, Orgera G, et al. Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation. J Vasc Interv Radiol. 2010 Jul;21(7):995-1003. Epub 2010 Jun 11. – Deloose K, Bosiers M, et al. Flemish Experience using the Advanta V12 stent-graft for the treatment of iliac occlusive disease. J of Cardiovascular Surgery, Feb 2007, Vol 48, number 1: 7-12 29 COBEST demonstrates covered and bare-metal stents produce similar and acceptable results for TASC B lesions. However, covered stents perform better for TASC C and D lesions than bare stents in longer-term patency and clinical outcome. (90% PP @ 18m) The use of covered balloon-expandable kissing stents for atherosclerotic aortic bifurcation occlusive disease provides superior patency at 2 years as compared with bare metal balloon-expandable stents. (92% @ 24m) Implantation of Advanta V12 PTFE-covered stent for iliac occlusive disease shows to be safe and feasible with excellent clinical results at 1 year in the investigated patient cohort. (91.1% @ 12 m)

30. FMRP 2014 | 30 Conclusion Tasc D lesion Tasc A lesion Tasc C lesionTasc B lesion Endovascular firstEndovascular All these findings support my personal recommendation : an endovascular-first approach for all aorto-iliac lesions