1. Aorta Infrarenal Stenosis: BE, SE or Covered Stents? CRT 2012
Rajesh M. Dave, MD, FACC, FSCAI
Chief Medical Executive, Cardiovascular Institute at Ortenzio Heart center, Holy Spirit Hospital
Chief, Department of Cardiology
Chairman, Cardiac Catheterization Laboratory
Camp Hill, PA

2. Rajesh M. Dave, MD Honoraria Abbott Laboratories
Atrium Medical Corporation
Cardiovascular Systems Inc.
Daiichi Sankyo
Bard Peripheral Vascular, Inc.
Pathway Medical Technologies, Inc.
Abiomed, Inc.
Ev3, Inc.

3. Infrarenal Aortic Lesions: ?PTA Vs Stent
PTA feasible: Restenosis in 30% of patients at 5 years 1
Limitations of PTA: risk of distal embolization, embolization of debris, Perforation, Underexpansion of lesions and recoil
Stents? Lower Restenosis , Less Recoil
Covered2 vs Bare, BE vs SE
Cardiovasc Interven Radiol :1-6
2. J Vasc Surg Dec; 54(6) :

4. Covered Vs Bare: general considerations
Covered Advantage: Protection against Perforation and embolization, two most critical complications
Covered Disadvantage: Limited size availability in
USA (e.g. I-Cast, Fluency, Viabahn, Aortic Cuffs)
Bare Stents, Advantages: Many choices, generally smaller sheath sizes
Bare disadvantage- Tissue proliferation-higher restenosis rates, especially in TASC C and D Lesions (shown in iliac lesions)

5. Covered Stents: Access Size and general considerations, Know your choices
Icast ( BE Covered): ( Under FDA review for On Label Iliac Indication)
-7F sheath compatible ( 10mm can be postdilated to 12mm)
-12mm stent 9F sheath ( 12mm stent can be expanded to 22mm) ( Not available in USA, investigational)
Fluency(SE covered): (Tracheobronchial indication) Max 10mm diameter
-Above 7mmx80mm stent requires 9F or above sheath, can go bareback
Viabahn (Iliac Indication, SE Covered): largest 13mm diameter, needs larger than 12F sheath
Wallstent Graft; ( SE Covered) ( Billiary): max size

6. Infrarenal Aortic Lesion : Considerations prior to treatment
With or Without Iliac Involvement
Calcification: Degree
Aneurysmal Vs Non Aneurysmal Disease
Ulcerations
Total Occlusion- Level
Size of Aorta: limited stent sizes in certain cases in USA
Relationship to surrounding vessels ie. Renals, Important collaterals etc.
Tolerability for access sheath size
Availability of IVUS, CTA, MRA

7. 84 yof Severe Claudication and Trash Feet

8. IVUS is almost Mandatory
In my lab, CTA
Eccentricity, Calcification

9. PTA 12mmX 30mm
9mmX59mm ICast

10. Postdilation by 14mm NC balloon

11. OUS Case: V12, Large Aorta of 16mm size
V12 stent not available for use in USA, investigational device in USA

12. Aortoiliac Involvement

13. Problem with Crossing Bilateral Iliac Bare
Stents: Avoid!!!

15. Icast 8mm X 59mm Bilaterally

16. Conclusions No Randomized trial exists between different stent types
Covered stents have significant advantage of Protection against Embolization, Perforation
Covered stent: Lower Restenosis
Covered BE: Precise Placement, small access sheath sizes, Limitation in current sizes

17. Conclusions
Covered SE: Larger sheath size or open access but larger size available in certain brands
BE Bare: Excellent choice for focal non calcified and non thrombotic lesion
SE Bare: Easy deployment, large sizes available up to 14mm
Bare Disadvantage? Higher restenosis, Higher embolization, perforation

18. My Personal Strategy
Associated aneurysm larger than 4cm or deep penetrating ulcers consider full endograft
Smaller than 14mm Aorta BE Covered is my first choice, In future if 12mms BE covered becomes available it will increase options, IVUS is MUST
Larger than 14mm aorta, mostly use Endograft Cuffs

19. Thank you