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TIPS & TRICKS FOR DIFFICULT ILIAC CTO LESIONS
- 1. Gustavo S. Oderich MD Professor of Surgery Director of Endovascular Therapy Division of Vascular and Endovascular Surgery TIPS & TRICKS FOR ILIAC CTO LESIONS
- 2. 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 devices Fenestrated, Branched Endografts, Atrium Maquet iCAST • Speaker fees for non-CME conferences WL Gore, Endologix * All consulting fees and grants paid to Mayo Clinic
- 5. Pre- Post-
- 6. • 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
- 7. ENDOVASCULAR APPROACH IS WIDELY ACCEPTED FOR TASC D LESIONS
- 8. Sixt et al. J Endovasc Ther 2012 ILIAC STENTING TASC A/B TASC C/D
- 9. TECHNICAL CONSIDERATIONS • Choice of approach Femoral (ipsi/contra) Brachial/ radial • Hybrid endarterectomy? • Adjuncts Atherectomy (debulking) Reentrance catheters/IVUS • Choice of balloons & stent Covered vs bare metal? Balloon vs self-expandable? • Aortic stenting (CERAB)?
- 10. 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
- 11. ANTEGRADE UP & OVER APPROACH
- 13. 5Fr MPA catheter 7Fr MPA Guide 7Fr Sheath 7Fr Raabe sheath 7Fr MPA guide5Fr MPA catheter
- 14. HYBRID FEMORAL ENDARTERECTOMY • Concomitant femoral bifurcation/ profunda disease • Preference for bovine pericardial patch • Before or after iliac stenting
- 16. Piazza et al. J Vasc Surg 2011 RESULTS OF FEMORAL ENDARTERECTOMY IN TASC D ILIAC LESIONS
- 17. ADJUNCTS FOR DIFFICULT ILIAC CTO • IVUS • Reentrance catheters • Atherectomy
- 18. IVUS technology combined with reentry device Dual channel device with IVUS Chromaflo
- 19. 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
- 21. 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 arteriesUndersize
- 22. Do not rebuild the aortic bifurcation unnecessarily high Separate aortic stenting then small overlap of iliac stents KISSING STENTS Too High Just right
- 23. • 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
- 24. Covered Endovascular Reconstruction Aortic Bifurcation Courtesy of Maquet Europe and Michel Reijnen P Goverde, M Reijnen, F Grimme
- 25. Adapted from Goverde, LINC 2013 Bare-Metal Stent Covered Stent NEO AORTIC BIFURCATION
- 26. 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
- 27. 1 stent = 4 shapes 12mm 20mm 12mm 18mm 16mm Courtesy of Peter Goverde and Michel Reijnen COVERED STENT Advanta V12
- 28. Covered iliac stents Rate of binary stenosis Author, year Design n Stent type Covered Uncovered Sabri, 2010 Retrospective 26 covered 28 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 covered 122 uncovered Mostly Self- Expandable 5yr:87% 5yr:53% Mwipatayi, 2011 RCT 83 covered 84 uncovered Balloon- Expandable 18mo:92% 18mo:75% Grimme, 2012 Retrospective 69 primary 46 re- intervention Balloon- Expandable P 1yr:95% P 2yr:90% R 1yr:88% R 2yr:82%
- 29. 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