© Borgis - New Medicine 2/2013, s. 39-43
*Witold Woźniak1, R. Krzysztof Mlosek2, Grzegorz Górski1, Tomasz Miłek1, Piotr Zydlewski1, Piotr Myrcha1, Piotr Ciostek1
Endovascular treatment of iliac artery occlusion
1First Department and Clinic of General and Vascular Surgery of the Second Faculty of Medicine, Medical University of Warsaw, Poland
Head of Department: prof. Piotr Ciostek, MD, PhD
2Department of Ultrasound Diagnostics and Mammography of the Second Faculty of Medicine, Medical University of Warsaw, Poland
Head of Department: prof. Wiesław Jakubowski, MD, PhD
Aim. The objective of the study was to analyze the results of endovascular treatment of iliac artery occlusion depending on the type of atherosclerotic lesions according to the TASC II classification.
Materials and methods. 46 patients with occlusion of the common iliac arteries and/or external arteries were operated in our clinic from 2008 to 2012. Based on the angio CT/angiogram results, the changes have been classified as type B (20), C (16) and D (10) according to the TASC II classification. The group included 37 male and 9 female aged 41-85 years, mean age 66.15ys.
Results. Following successful percutaneous iliac artery angioplasty stent was implanted in 37 patients, whilst in 9 cases no stent was applied. Significant complications were observed in five patients: unstable coronary heart disease - 1 case, pseudoaneurysm of femoral artery 1 case, peripheral arterial embolism- 2 cases. A case of iatrogenic external iliac artery rupture with haemorrhage into the retroperitoneal space was noted. This patient required open surgery. All patients have been followed up to one year. At that time primary assisted patency was noted to be 100%.
Conclusions. 1. All TASC types of chronic iliac artery occlusion can be successfully managed using intravascular methods, with acceptable complication and conversion to open surgery rate. 2. Midterm results (annual primary assisted patency) have been very satisfactory. 3. Long-term patency of iliac artery angioplasty still require further investigation.
Technological progress of endovascular surgery, growing experience of centres using this method changed clinical indications to these operations. Advanced cases of lower limb atherosclerosis can be more successfully treated endovascularily. Previously, only cases of arterial stenosis were qualified for endovascular procedures, while currently angioplasty is increasingly used in patients with occlusion of lengthy arterial segments. Changes located in the aorto-iliac segment represent about 30% of lower limb atherosclerosis (1). Consensus TASC II (Trans Atlantic Inter-Society Consensus II) divides atherosclerotic lesions in this segment into four groups A, B, C and D. This classification takes into account the morphology and degree of atherosclerotic changes in the aorta and the iliac arteries (tab. 1). According to TASC II guidelines, endovascular method is a treatment of choice for group A. Group D lesions are scheduled routinely for classic aorto-iliac/femoral by pass surgery. Groups B and C are considered intermediate, both methods can be used. In group B intravascular method is preferred, whilst in Group C rather classic operation (2, 3). Based on these recommendations, major part of patients with aorto-iliac arterial occlusion should be operated in a classic manner. Aorto-ilio-femoral bypass is extensive surgical procedure and therefore risk of major postoperative complications is significant. On the other hand, endovascular treatment of iliac artery occlusion, if only feasible, is relatively safe and appears encouraging.
Table 1. The TASC II classification of atherosclerotic lesions in the aorto-iliac segment.
|Type A Lesions|
– Unilateral or Bilateral Stenoses of CIA
– Unilateral or Bilateral Single Short (≤ 3 cm) Stenosis of EIA
|Type B Lesions|
– Short (≤ 3 cm) Stenosis of Infrarenal Aorta
– Unilateral CIA Occlusion
– Single or Multiple Stenosis Totaling 3-10 cm Involving the EIA Not Extending Into the CFA
– Unilateral EIA Occlusion Not Involving the Origins of Internal Iliac Or CFA
|Type C Lesions|
– Bilateral CIA Occlusions
– Bilateral EIA Stenosis 3-10cm Long Not Extending Into the CFA
– Unilateral EIA Stenosis Extending Into the CFA
– Unilateral EIA Occlusions That Involves the Origins of Internal Iliac and/or CFA
– Heavity Calcified Unilateral EIA Occlusion With Or Without Involvement of Origins of Internal Iliac and/or CFA
|Type D Lesions|
– Infra-renal Aortoiliac Occlusion
– Diffuse Disease Involving the Aorta and Both Iliac Arteries Requiring Treatment
– Diffuse Multiple Stenoses Involving the Unilateral CIA, EIA, and CFA
– Unilateral Occlusions of both CFA and EIA
– Bilateral Occlusions of EIA Iliac Stenoses in Patients with AAA Requiring Treatment and Not Amenable of Endograft Placement or Other Lesions
– Requiring Open Aortic or Iliac Surgery
This study aimed to analyze the results of endovascular treatment of iliac artery occlusion in different TASC II types of atherosclerotic lesions.
MATERIALS AND METHODS
From 2008 to 2012, 46 patients with the occlusion of the common iliac arteries and/or external arteries were operated in our clinic. The group included 37 male and 9 female, aged 41-85 years, mean age 66.15 ys. The basic data of patients have been presented in table 2. The predominant clinical symptoms included intermittent claudication at distance below 100m, rest pain and tissue damage-toe/forefoot necrosis. The indications for surgery have been determined based on a physical examination and the imaging tests (ultrasound, computed tomography angiography). The patients with limb ischemia at the stages IIB, III and IV according to Fontaine were qualified for endovascular surgery. Based on angio CT/angiogram results, and according to TASC II classification, cases have been classified as type B (20), C (16) and D (10). Lower limb angiogram was performed via contralateral common femoral (30 cases) or axillary (12 cases) artery access. In four cases ipsilateral antegrade femoral artery access has been established. The procedure required local anaesthesia with 1% Xylocaine. A diagnostic catheter was inserted into the distal segment of abdominal aorta. Then, localisation and degree of arterial stenosis could be precisely analyzed. Arterial occlusion was negotiated by subintimal dissection with Terumo guidewire. Standard loop technique was performed. Then intraluminal re-entry was completed and confirmed on angiogram. At this stage any arterial perforation/extravasation was excluded. Then unfractioned heparin at a dose of 0.5 mg/kg of the body weight was administered intravenously. Angioplasty was performed using balloon catheters 7-10 mm in a diameter and 40-100 mm long. Final result was evaluated by control angiography. In case of residual stenosis or dissection of the iliac artery, a stent was implanted. Following surgery low molecular weight heparin was administered for 72 hours. Clopidogrel antiplatelet therapy (75 mg o.d.) administered for 3-6 months, was afterwards replaced by acetylsalicylic acid. The clinical result was assessed based on regression of pain, distance of intermittent claudication and rate of healing of trophic lesions. A follow up ultrasound was carried out at 1, 6 and 12 months post angioplasty. In case of doubt computerized tomography angiography was performed.
Table 2. The basic clinical data of patients qualified for endovascular treatment of iliac artery occlusion.
| ||Number of patients||Percentage|
|Ischemic heart disease||24||52.8%|
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