Andrew Bunney MD, PGY-4 University of Minnesota bunne035@umn.edu

Chief Complaint and HPI CC: Pulseless RLE HPI: 46 year old male with a history of severe atherosclerotic disease which had required multiple procedures, including bilateral iliac artery stent placement. The patient has been noncompliant with medications, including anticoagulation, for the past 4 months. Presented with sharp RLE pain. PE found a pulseless RLE.

PMH, PSH, Drugs, Allergies PMH: DM type 2, COPD, Depression, CAD with MI, HTN, HLP, severe PAD PSH: Multiple bi-iliac interventions with angioplasty and stenting 2-3 years prior to presentation. Social History: Smoking 1ppd, ETOH Medications: ASA 325mg, Insulin 70U/day, Lisinopril 10mg, Gemfibrozil 600mg BID Allergies: Plavix

Noninvasive Imaging Oblique MIP image of CTA demonstrating occluded distal aorta and R CIA stent. R EIA partially patent but occluded distally with patent R CFA. Oblique MIP image of CTA demonstrating occluded distal aorta and L CIA stent. L EIA and L CFA appear patent with long stenosis of L EIA.

Noninvasive Imaging

Diagnosis and Discussion Diagnosis: Acute Aortobi-iliac occlusion with critical RLE ischemia manifested by rest pain (Fontaine stage III or Rutherford grade II). Treatment choice in aortoiliac disease depends on complexity of lesion. Can use the TransAtlantic InterSociety Consensus (TASC II) criteria, established in 2007. Type A and B lesions treatment of choice with endovascular therapy Type C and D lesions treatment of choice with surgery This lesion is a type D lesion, primary treatment is generally considered to be open surgery. Given the severe occlusive disease on CTA and high perioperative cardiac risk (calculated at 11%), the patient was considered not to be a good surgical candidate for reconstruction. Interventional radiology was consulted to attempt endovascular revascularization. TASC Type A TASC Type B TASC Type C TASC Type D

Possible Complications A major complication is defined by any complication that results in additional therapy or prolonged hospitalization. 4.3% for iliac PTA and 5.2% for iliac stenting. 30-day mortality rate of 1% for iliac PTA and 0.8% for iliac stenting. Arterial rupture (0.8-0.9%) Distal Embolization Stent Infections Arterioureteric fistula after iliac stenting – one reported case Dissections Access site pseudoanuerysm or hematoma

Intervention Right CFA access was obtained. Occlusion was crossed and an aortogram obtained. Left CFA access obtained and occlusion crossed. Thrombolytics started at 0.5mg/hr through both sheaths. Post thrombolytics angiogram showed recanalization of the occlusion.

Intervention Multifocal stenoses visualized in aorta and common iliacs. Opted for further treatment with aortic stenting and extension of previous bi-iliac stents using a chimney technique. A 4cm long 14mm diameter self expanding stent was deployed from the right CFA access 2cm inferior to the renal arteries. Stent was post-dilated with 10 and 12 mm balloons. Wire access from the left CFA was adjusted from an extraluminal to intraluminal position so both CFA accesses have continuity with the true lumen of the aorta. Next, a 8mm x 10cm long Viabahn covered self-expanding stent was placed from the aorta to the L CIA and a 8mm x 15cm long Viabahn covered self-expanding stent placed from the aorta to the R CIA simultaneously. Both stents post-dilated with 6mm balloons using a kissing technique. Residual stenosis was seen in the proximal L EIA (not pictured). A 8mm x 8cm self-expanding stent was placed just distal to the patent L inferior epigastric artery and post-dilated with a 6mm balloon. Final angiogram demonstrates technical success with patent aortobi-iliac flow. Focal dissection at distal L CIA near hypogastric takeoff treated with PTA.

Intervention Followup CTA performed 5 months after intervention shows patent stents with focal stenosis between the L CIA and L EIA stents. This was successfully angioplastied in a followup procedure.

Summary Intervention 5 year patency 10 year patency 90% 75% TASC C and D lesions, although traditionally treated surgically, can be successfully managed with an endovascular approach with comparable patency rates. One recent study states that outcomes of aortic or aortic bifurcation interventions had no significant difference in outcomes from iliac interventions for TASC C and D lesions. Study of 292 aortic bifurcation lesions and 83 distal aorta/bifurcation lesions compared to 1337 iliac lesions. Current guidelines recommend antiplatelet therapy with ASA or clopidogrel at the time of endovascular intervention and continuation indefinitely to help prevent stent thrombus. Surveillance varies. Our institution follows our patients in clinic at 3, 6 and 12 months after intervention and then annually. Ultrasound or other imaging is done on a clinical basis. Intervention 5 year patency 10 year patency Endovascular Iliac Stent 70-93% (92-95% 2ndary) 65-68% (87% 2ndary) Aortobi-iliac Surgical bypass graft 90% 75% Ax-unifemoral 44-79% Ax-bifem 50-76% Fem-fem 55-92%

References Nieson M. Endovascular Management of Aortoiliac Occlusive Disease. Seminars in Interventional Radiology 2009;26(4):296-302. Ahn S, Murphy T. Aortoiliac Angioplasty and Stents. Handbook of Interventional Radiologic Procedures. Lipincott Williams and Wilkins, New York 2011. Norgren L et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Journal of Vascular Surgery 2007;45:S5-67. Yin M et al. Endovascular Interventions for TransAtlantic InterSociety Consensus II C and D Femoropopliteal lesions. Chin Med J 2013;126:415-420. Baril DT et al . Endovascular interventions for TASC II D femoropopliteal lesions. J Vasc Surg 2010; 51: 1406-1412. Piazza M et al. Iliac artery stenting combined with open femoral endarterectomy is as effective as open surgical reconstruction for severe iliac and common femoral occlusive disease. J Vasc Surgery 2011;54(2):402-411. Balzer J O et al. Percutaneous interventional reconstruction of the iliac arteries: primary and long-term success rate in selected TASC C and D lesions. Eur Radiol.2006;16:124–131.  Leville C D et al. Endovascular management of iliac artery occlusions: extending treatment to TransAtlantic Inter-Society Consensus class C and D patients. J Vasc Surg. 2006;43:32–39.  Sixt S et al. 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. 2008;15:408–416. Sixt S et al. Endovascular Treatment for Extensive Aortoiliac Artery Reconstruction: A Single-Center Experience based on 1712 Interventions. J Endovasc Ther 2013;20(1):64-73.

Questions? bunne035@umn.edu