Primary stenting for aortic lesions: From single stenoses to total aortoiliac occlusions
Article Outline
Purpose
This study evaluated the feasibility, safety, and efficacy of primary stenting in atherosclerotic stenoses and occlusions of the infrarenal aorta.
Methods
Between January 2003 and December 2006, 12 patients (6 men) with a mean age of 66.3 ± 4.1 years who had infrarenal aortic occlusive disease were treated with primary stenting (aortic stenosis, 8; chronic total aortobiiliac occlusion, 4). Reasons for referral were severe claudication in six patients (50%), ischemic rest pain in four (33.3%), and minor tissue loss in two (16.7%). Three patients (25%) had chronic renal failure and were on dialysis. Follow-up was performed in all 12 patients.
Results
Technical success was 91.7% because one patient had a residual stenosis >30% after stent placement and balloon postdilation owing to severe calcification of the aorta. However, clinical and immediate hemodynamic success was achieved in all 12 patients (100%). The preprocedural mean resting ankle-brachial index (ABI) values of 0.56 ± 0.13 at the right side and 0.59 ± 0.15 at the left were increased to 0.97 ± 0.04 and 0.95 ± 0.06, respectively, after treatment (P < .01). At the end of the mean follow-up of 18.3 months (range, 6-37 months), the primary clinical and hemodynamic patency was 91.7% ± 7.98%, and the mean resting ABI values were 0.96 ± 0.04 for the right and 0.92 ± 0.1 for the left side (P < .01 compared with preinterventional values). None of the patients in the study underwent reintervention. An access-related groin hematoma developed in one patient, but no other major or minor complications occurred. One patient died 8 months after the procedure of chronic renal failure complications.
Conclusion
Primary stenting is feasible, safe, and effective for the whole spectrum of aortic occlusive disease. Especially for patients with infrarenal aortic stenoses, it is recommended as the first-line treatment and should be considered as a viable alternative to surgery for total aortoiliac occlusions.
Two different patterns of atherosclerotic disease affect the infra-renal aorta: (1) localized lesions of the aortic bifurcation involving the lower part of the abdominal aorta and the common iliac arteries, whether symmetric or not, and (2) isolated lesions of the infrarenal aorta without involvement of the aortic bifurcation. The latter pattern of aortic occlusive disease is relatively rarely observed. It occurs more frequently in women aged 30 to 50 years who are heavy smokers.1
Surgery, either with bypass graft or aortic endarterectomy, has been the traditional standard of care for infrarenal aortic occlusive disease, with good long-term patency rates of 70% to 75% at 10 years but a 5% to 10% early complication rate.2, 3, 4 Percutaneous transluminal angioplasty (PTA) has been proposed as an alternative to surgery, and several series have demonstrated its safety and efficacy in localized stenoses of the distal infrarenal aorta5, 6, 7, 8, 9, 10, 11 as well as in lesions involving the aortic bifurcation.5, 6, 7, 10
Stenting offers theoretic advantages over PTA, and its use has been established in several vascular beds, with excellent patency rates.12 In the infrarenal aorta, however, only a small number of studies to date have evaluated the results of primary stenting for localized stenoses,13, 14, 15, 16 whereas total aortic occlusions have been conventionally considered as a relative contraindication for endovascular therapy. In this series, we report our experience with primary stenting for aortic occlusive disease, ranging from single infrarenal aortic stenoses to extended chronic total aortobiiliac occlusions.
Methods
Patients
The medical records of all patients with aortic occlusive disease ranging from isolated localized aortic stenosis to total occlusion of the infrarenal aorta extending or not to the iliac arteries that were treated using percutaneous endovascular techniques (PTA) techniques during the period January 2003 to December 2006 were retrospectively analyzed for this study. Patients with aortic bifurcation lesions that actually represented iliac artery disease were not included in this analysis. Twelve patients met the inclusion criteria. All patients provided informed consent.
Atherosclerosis risk factors as well as preprocedural and postprocedural clinical symptoms were registered in all patients. Ankle-brachial indexes (ABIs) at rest were also calculated. Patients with claudication had been offered conservative treatment, including exercise programs along with cardiovascular risk factor modification, for ≥6 months before intervention; however, no significant clinical improvement was noticed in any of them.
Before admission in our department, 10 of the 12 patients were evaluated with digital subtraction angiography and two with magnetic resonance angiography. Six patients (50%) had isolated aortic stenosis without bifurcation involvement (4 at the mid and 2 at the lower portion of the infrarenal aorta). Five of these lesions were ≤3cm in length (TransAtlantic Inter-Society Consensus [TASC] B), and one was >3 cm. Four patients (33.3%) had chronic total aortobiiliac occlusion (TASC D). One patient (8.3%) had focal aortic stenosis and chronic occlusion of the right common (CIA) and external iliac artery (EIA) extending to the origin of the common femoral artery (CFA; TASC D). Finally, the remaining patient (8.3%) had two separate localized stenoses in the infrarenal aorta along with right CIA stenosis and chronic left CIA and EIA occlusion extending to the proximal CFA (TASC D). All stenoses were of atherosclerotic origin and ≥60% as determined by angiograms. All 12 patients had patent femoropopliteal segments and good distal runoff scores ≥2.
Procedure
Stenting procedures were performed in the endovascular suite of our department under local anesthesia supplemented with intravenous sedation and analgesia when indicated. The patients were monitored with pulse oximetry, electrocardiography, and blood pressure. Preoperatively, all patients were receiving long-term antiplatelet therapy.
Three different approaches were used with regard to the localization and extent of the lesions.
1. For stenoses without bifurcation involvement located at the mid segment of the infrarenal aorta, a unilateral retrograde femoral approach was used. A long introducer sheath with appropriate diameter (10F-12F) matching the size of the intended stent was placed at the ipsilateral common femoral artery, and a bolus of heparin (5000 IU) was given intravenously. An initial angiography was then performed through the introducer sheath.
The stenosis was crossed with a 0.035-in steerable guidewire alone or combined with a selective catheter, followed by direct aortic stenting. Self-expanding stents were appropriately placed to well cover the entire lesion. Balloon widening of the stents was carefully performed with a single aortic dilation balloon (14-16 mm in diameter) that was inflated ≤3 atm and was discontinued immediately at any patient reaction indicating pain. When balloon expandable stents were placed, they were advanced protected in the long sheaths that were withdrawn after appropriate stent positioning.
2. For distal isolated aortic stenoses located close to but not involving the aortic bifurcation, the kissing technique was used. Two 6F sheaths were introduced in both CFAs, and the stenosis was bilaterally crossed with two steerable guidewires. Iliac kissing stents were deployed appropriately, well covering the aortic lesion. Stent widening was performed with kissing balloons (8-9 mm in diameter).
3. In patients with chronic aortobiiliac occlusion, bilateral, short 6F sheaths were introduced percutaneously through the common femoral arteries. The occlusions were crossed bilaterally using the coaxial technique with 0.035-in straight, stiff-type hydrophilic Terumo guidewires combined with straight 4F hydrophilic catheters (Terumo Corp, Tokyo, Japan). Angled guidewires and catheters were not used to avoid subintimal passage. Conservative kissing predilation was then performed with small diameter balloons of 6 to 8 mm to facilitate stent advancement; the degree of dilation was much less than the estimated normal vessel lumen to minimize the bulk of debris and the possibility of distal embolization and avoid aortic rupture.
If initial aortic and iliac arteries recanalization was successful, the 6F sheaths were exchanged for long sheaths of appropriate size for stent advancement. Self-expanding aortic stents were then positioned and deployed appropriately in the infrarenal aorta, followed by simultaneous bilateral deployment of the iliac “stent-limbs.” The latter were placed in continuity with the aortic stents to trap the possible generated atherothrombotic debris and to prevent the development of a new lesion within the nonstented segment of the aortic bifurcation.
At the end of the procedure, a completion angiogram was performed for demonstration of the final result and screening of asymptomatic distal embolization. Hemostasis was achieved by local pressure alone. Especially after large (12F) sheath removal, prolonged (≥30 min) manual compression was applied, followed by overnight bed rest.
The stents used included 11 self expanding Sinus-XL (diameter, 14-18 mm; length, 40-60 mm; OptiMed, Ettlingen, Germany), and two Palmaz P 4014 and two Palmaz P5014 balloon-expandable aortic stents (Cordis, Johnson & Johnson, Warren, NJ) were placed, with the latter being preferred in heavily calcified lesions. A total of 15 Sinus 6F (OptiMed) self-expanding iliac stents were used (diameter, 8-9 mm; length, 40-80 mm). Aortic stents were placed so that they would not limit future open repair if needed. Stent sizing was based on the lumen diameter of the native healthy aorta just proximal or distal to the lesion that was measured on the preprocedural angiogram. Self-expanding stents were oversized up to 5%. The stent length chosen was the shortest one appropriate for complete coverage of the lesion and adequate proximal and distal attachment to healthy aortic segments.
After the procedure, double antiplatelet treatment with aspirin (100 mg/d) and clopidogrel (75 mg/d) was administered for 1 month, and then monotherapy with clopidogrel (75 mg/d) was continued long term unless contraindicated.
Technical success was obtained if the residual stenosis as measured on angiogram was ≤30% or the mean pressure gradient across the lesion was ≤10 mm Hg.17 Immediate hemodynamic success was determined by an increase in ABI of ≥0.10 from baseline at the first clinical follow-up.18 Clinical success was defined as improvement in walking distance, absence of resting pain, and healing of trophic changes after stent placement.19
After stent deployment, femoral pulses were palpated and ABIs at rest were measured in all patients. Follow-up at 1, 3, and 6 months postprocedure and biannually thereafter included physical examination, ABI measurements, and duplex ultrasound (DUS) scanning. Clinical patency was defined as the continued absence or improvement of symptoms and hemodynamic patency as stenosis <50% at DUS scan.16, 17 During the latter, the whole stented segment was scanned to locate areas with high peak systolic velocities, which were then compared with the velocities recorded immediately upstream and downstream. The value of the highest proportional velocity change was used as the criterion for stenosis grading. For a ≥50% aortoiliac stenosis, a peak systolic velocity ratio ≥2.5 was used.
Angiography was performed only in cases of recurrent stenosis >50% as measured on DUS scans combined with deterioration in walking distance. Two patients underwent follow-up angiography concomitantly with angiographic evaluation for carotid artery disease.
Statistical analysis was done with SPSS 10.0 software (SPSS Inc, Chicago, Ill). The persistence of patency during follow-up was reported by Kaplan-Meier life-table analysis. The preprocedural and postprocedural ABIs were compared by Student t test. Statistical significance was taken at P < .05.
Results
Patients’ characteristics are summarized in Table I. Six patients (50%) were men. The mean age was 66.3 years (range, 62-73 years). Three patients (25%) had chronic renal failure and were receiving dialysis. Six patients (50%) were referred because of severe claudication (Rutherford Classification20 - Category 3) 4 patients (33.3%) due to ischemic rest pain (Category 4) and 2 patients (16.7%) due to minor tissue loss (Category 5). Preprocedural mean resting ABIs were 0.56 ± 0.13 at the right side and 0.59 ± 0.15 at the left side. In the eight patients with patent aortas, mean aortic stenosis before the procedure was 71% (range, 60%-85%).
Table I. Population characteristics and preinterventional clinical classification
| Characteristic | Mean ± SD, or No. (%) |
|---|---|
| Age, y | 66.3 ± 4.1 |
| Sex | |
 Males | 6(50) |
| Females | 6(50) |
| Cardiovascular risk factors | |
| Smoking | 9(75) |
| Hypertension | 5(41.7) |
| Diabetes mellitus | 4(33.3) |
| Hypercholesterolemia | 7(58.3) |
| Chronic renal failure⁎ | 3(25) |
| Preintervention categories by Rutherford classification† | |
| 1 (mild claudication) | 0(0) |
| 2 (moderate claudication) | 0(0) |
| 3 (severe claudication) | 6(50) |
| 4 (ischemic rest pain) | 4(33.3) |
| 5 (minor tissue loss) | 2(16.7) |
| 6 (major tissue loss) | 0(0) |
⁎Patient on dialysis. |
†Category 1, treadmill exercise completed (5 min at 2 mph on a 12% incline), postexercise ankle pressure (AP) >50 mm Hg but >25 mm Hg less than normal; category 2, symptoms between categories 1 and 3; category 3, treadmill exercise cannot be completed, postexercise AP <50 mm Hg; category 4, resting AP of <40 mm Hg; category 5, nonhealing ulcer, focal gangrene; category 6, extending above the transmetatarsal level, functional foot no longer salvageable. |
Four patients with localized stenosis at the mid portion of the infrarenal aorta were treated with primary aortic stenting (Fig 1), whereas in two patients with distal aortic stenosis close to but not involving the aortic bifurcation, iliac kissing stents were placed. Four patients with chronic total aortobiiliac occlusion were treated with aortic stents and iliac kissing stents that were deployed contiguously (Fig 2, Fig 3). Three of these patients were judged poor surgical candidates: one had coronary artery disease with impaired ejection fraction, one was obese with severe chronic obstructive pulmonary disease due to heavy smoking, and one had a hostile abdomen due to previous operations. One patient refused open surgery.
Fig 1.
A, Digital subtraction angiography demonstrates isolated stenosis at the mid-portion of the infrarenal aorta transversed with a long sheath. B, Successful deployment of a balloon-expandable aortic stent without residual stenosis.
Fig 2.
A, Preprocedural digital subtraction angiography demonstrates total aortobiiliac occlusion. B, Treatment with two aortic and iliac stents deployed contiguously. C, At 9 months postoperatively, the aortic and iliac stents remain widely patent.
Fig 3.
A, Total aortobiiliac occlusion treated successfully with primary stenting of the (B) infrarenal aorta and common iliac arteries.
One patient with localized infrarenal aortic stenosis and right CIA and EIA chronic occlusion extending to the CFA underwent aortic stenting and a femorofemoral bypass graft. Finally, one patient with two separate localized isolated stenoses at the infrarenal aorta, chronic left CIA and EIA occlusion, and right CIA stenosis, underwent aortouniiliac stenting with three stents (two aortic, one iliac), along with a femorofemoral bypass graft. Actually, no attempts for endovascular recanalization of the iliac occlusions were made in these two patients owing to anatomic limitations (restricted working length for sheath and wire insertion in the CFA) and theoretic concerns (increased possibility of damage stent placed in the CFA due to the repeated motions of the hip joint).
Technical success was obtained in 11 of 12 patients (91.7%). One patient was considered to be immediate technical failure. This hypertensive and hypercholesterolemic 62-year-old man with chronic renal failure was admitted with severe claudication (Rutherford category 3) caused by right common iliac artery stenosis and left iliac segment occlusion (TASC D). He had good distal run-off with two patent crural arteries. Despite aortic stenting and balloon postdilation, the aortic stenoses were not completely dilated owing to severe calcification, thus resulting in an immediate technical failure with residual stenoses >30%.
Clinical success, however, was 100% immediately after the procedure. The six patients with severe claudication, including the one with residual stenosis >30%, reported improvement in walking distance. Four patients who had resting pain before the procedure reported they were free of their symptoms postoperatively, and bilateral trophic changes in the remaining two patients were healed completely 4 months after the procedure.
Immediate hemodynamic success was 100%. After the procedure, the mean resting ABI increased to 0.97 ± 0.04 at the right side and to 0.95 ± 0.06 at the left side (P < .01 compared with preinterventional values).
No deaths occurred ≤30 days after stent implantation, nor were there any aortic ruptures or any other major complications. A minor groin hematoma that developed in one patient was treated conservatively and did not require any further intervention. No other early complications occurred in this series.
During a mean follow-up of 18.3 months (range, 6-37 months), the stented arteries remained patent in all but one patient, a 73-year-old woman who was a heavy smoker, hypertensive, and hypercholesterolemic. She initially had severe bilateral claudication (Rutherford category 3) due to chronic aortobiiliac occlusion (TASC D). She had good distal run-off with three patent crural arteries. The patient was treated successfully with two aortic and two iliac kissing stents. She had a notable clinical improvement after the procedure; however, she returned 4 months postoperatively with recurrent left lower extremity ischemia owing to left common iliac artery reocclusion. Although she refused reintervention despite our suggestions, her left lower extremity remained viable without any significant trophic changes until the most recent follow-up. In the rest of the patients, DUS imaging did not reveal any other restenosis in any of the stented arteries during the follow-up period. One patient died 8 months after the procedure of complications from chronic renal failure.
Kaplan-Meier life-table analysis of primary patency is shown in Fig 4. At the end of follow-up, the primary clinical and hemodynamic patency was 91.7% ± 7.98%. Post-interventional ABI improvement was maintained for the whole graphed time period. The mean resting ABI values at the most recent available follow-up were 0.96 ± 0.04 for the right side and for the 0.92 ± 0.1 left side (P < .01 compared with preinterventional values).
Fig 4.
Kaplan-Meier life-table analysis of primary patency after stenting of aortic localized stenoses and total occlusions.
No patients in this series underwent reintervention during the follow-up period.
Mean hospitalization time after stent placement was 2.3 ± 1.37 days. Three patients were hospitalized for 1 day, six for 2 days, and one for 3 days owing to an access site hematoma. Finally, two patients who underwent a femorofemoral bypass in addition to stent placement were discharged 5 days postoperatively.
In summary, two treatment failures were noticed in this series: one immediate technical failure due to residual stenosis >30% and one late failure secondary to an iliac stent reocclusion.
Discussion
Focal stenosis or occlusion of the infrarenal aorta is a relatively rare entity.16 It most commonly affects younger patients with less extensive atherosclerotic lesions compared with those who have iliofemoral or more distal disease.19 Female sex, heavy smoking, elevated blood lipid concentrations, and the hypoplastic aorta syndrome are among the most important risk factors.1, 19, 21
Aortobifemoral bypass or aortic endarterectomy has been the traditional treatment of choice for infrarenal aortic occlusive disease with well-documented long term results,2, 3, 4 In carefully selected patients, the 11-year cumulative patency rate after localized endarterectomy of the abdominal aorta is 86 %,4 whereas long-term patency after aortobifemoral bypass is reported to be up to 90% at 5 years and 75% at 10 years.22, 23 These procedures, however, are associated with significant morbidity and mortality24, 25, 26 and may also lead to sexual dysfunction in up to a third of men.27
PTA, which was initially introduced for aortic lesions in 1980 by Grollmann et al,28 Velasquez et al,29 and Tegtmeyer et al,30 has been proposed as an alternative to surgery. Since then, several series have been published demonstrating successful results of PTA in localized stenoses involving the infrarenal aorta5, 6, 7, 8, 9, 10, 11 as well as the aortic bifurcation.5, 6, 7, 10 Aortic PTA has a satisfactory immediate outcome, with initial technical success up to 95% to 100%7, 19, 31; however, its mid- and long-term efficacy is frequently compromised due to restenosis.10
Stenting may overcome the suboptimal results of PTA. Although to our knowledge to date no prospective randomized trials have compared the two techniques, stent implantation is theoretically superior to PTA because it provides a smooth cylindrical lumen that favors nonturbulent flow, thus minimizing the possibility of thrombus formation and subsequent aortic lumen restenosis.16 In addition, stenting reduces the recoil effect after PTA, especially in calcified “hard” aortic lesions, whereas the consequences of in-stent neointimal hyperplasia are not so crucial in a large diameter vessel such as the aorta.
Unlike the iliofemoral territory, stenting has been infrequently documented in the infrarenal aorta. First, Diethrich et al13 began in 1990 to offer stent therapy to patients with abdominal aortic lesions that were considered to be at high risk for conventional surgery. In 24 patients, they reported a 100% cumulative primary patency at 5 years. Since then, a limited number of series have studied the efficacy of stent placement in the infrarenal aorta. Technical success in these studies was 82% to 100%, whereas primary patency rates were 83% to 100% during the short- and mid-term follow-up.13, 15, 16, 17, 32, 33, 34, 35, 36, 37
In most of these series, aortic stents were implanted after predilation. In our study, however, all eight patients who had localized aortic stenoses were treated successfully with direct stenting without predilation. Covering the lesion with a stent before angioplasty may reduce the possibility of distal embolization because the potentially embolic material is trapped between the stent and the arterial wall. In addition, stenting without predilation, although not clinically proven, may minimize the risk of vessel rupture by distributing the dilating forces more evenly against the aortic wall.32 Direct stenting therefore may be preferable to stent implantation after predilation.
To our knowledge, only five small studies with a total of 93 patents have been published in English reporting direct aortic stenting without predilation (Table II).17, 32, 33, 34, 35, 36, 37 Prospective randomized studies are necessary to definitely clarify this issue; however, because such evidence is not currently available, the decision regarding predilation of the aorta is based mainly on arbitrary data and physicians’ personal opinions.
Table II. Results of direct stenting for distal aortic occlusive disease
| First author | Year | No of cases | Age (range)⁎ | Stenosis/occlusion | Technical success (%) | Major complications | Mean follow-up, mon (range) | Primary patency (%) |
|---|---|---|---|---|---|---|---|---|
| Sheeran.35 | 1997 | 9 | 61(49-73) | 9/0 | 100 | 0 | 19(2-36) | 89 |
| Nyman.33 | 2000 | 30 | 61(42-80) | 21/9 | 93 | 4 | 19(5-60) | 97 |
| Yilmaz.32 | 2004 | 13 | 57 | 13/0 | 100 | 0 | 43(12-96) | 100 |
| Schedel17 | 2004 | 15 | 54(46-62) | 15/0 | 87 | 3 | 36(12-46) | 85 |
| Poncyljusz37 | 2006 | 26 | 57(43-72) | 26/0 | 100 | 0 | 18(12-24) | 100 |
| Present study | 12 | 66.3(62-73) | 8/4 | 91.7 | 0 | 18(6-37) | 91.7 |
⁎Mean and median age as provided by each author. |
Four patients with chronic total aortobiiliac occlusion were treated successfully (PTA plus stenting) without previous thrombolysis in this series. Although stenting of total aortic occlusions after initial thrombolysis has been reported relatively frequently,14, 16, 33, 34, 38 apart from the present study, only one case series39 has documented successful recanalization and stenting of extended total aortobiiliac occlusions without adjunctive thrombolytic therapy. The latter, although commonly useful in acute or subacute obstructions, has an unpredictable efficacy in chronic occlusions.40 Thrombolytic therapy is also associated with an increased risk for hemorrhage: bleeding from venous puncture sites occurs in up to 68% of the patients,40 and groin hematomas and fatal hemorrhage have also been reported.33, 41 As a consequence, we avoided thrombolysis in our patients and proceeded directly with PTA and stenting. Recanalization was achieved in all four cases, thus implying a promising role of primary stenting without thrombolysis even for TASC D41 chronic total aortoiliac occlusions. Further studies with larger number of patients are needed to confirm these findings.
Self-expanding aortic stents were used in most of the patients in this series. The latter, due to their continuous radial force, may achieve gradual expansion after balloon widening, allowing for the use of smaller-sized balloons and thus minimizing the risk of aortic rupture. Self-expanding endoprostheses may also trap atherothrombotic material more effectively owing to their smaller struts and theoretically reducing the possibility of distal embolization,32 which is probably more likely to occur in noncalcified “soft” aortic plaques and total aortic occlusions. Finally, for iliac artery lesions, only self-expanding stents were used owing to their superior flexibility and ability to adapt to vessel tortuosity.39
Balloon-expandable stents were placed preferentially in patients with calcified aortic lesions. It is considered that such stents perform better in highly calcified “hard” aortic plaques because of their enhanced radial force.33 In addition, placement of a self-expanding stent on hard calcified lesions without predilation may lead to incomplete deployment of its edges, especially if the stent is not centered on the lesion or its length is not sufficient enough to cover both proximal and distal healthy sides of the aorta (Fig 5, D and E). It is therefore suggested that if self-expanding stents are selected to treat calcified aortic stenoses, they should be centered on the lesion. In addition, their length should be greater than the lesions they are intended to cover in order to secure complete deployment of their edges and subsequently allow for safe balloon catheter advancement (Fig 5, A and C).
Fig 5.
A, Drawing shows eccentric calcified aortic stenosis. B, Placement of a self-expanding stent, centered on the lesion, with adequate length achieving complete deployment of its edges in healthy aortic segments. C, Successful postdilation of the stented lesion. D, Inappropriate placement of a noncentered, small-length, self-expanding stent results in (E) difficulties in subsequent balloon catheter advancement due to incomplete deployment of its distal edge.
As mentioned, patients who have aortic occlusive disease are relatively young, have a longer life expectancy compared with the average patient with claudication, and thus are more likely to need secondary interventions.21 In such a scenario, percutaneous procedures can be repeated with less technical difficulties compared with surgical revision in a previously operated on field with scar tissue and distorted anatomy. Thus, endovascular therapy may be advantageous in this patient group and might be considered the treatment of choice.
No symptoms of mesenteric ischemia developed postoperatively in any of the patients in this series. Although one could argue that implantation of a stent across the inferior mesenteric artery (IMA) should be avoided, we believe that this is not routinely a major factor in stent placement, because patency of this artery is usually maintained despite enjailment of its ostia.36, 38 But even if the IMA is occluded after stent placement, it should be considered acceptable as long as the patient remains asymptomatic because during aortic surgery, the IMA is commonly sacrificed as part of the procedure. Only in cases of superior mesenteric/celiac artery occlusive disease, enlarged and meandering IMA, or bilateral hypogastric artery occlusion, stent covering of the IMA orifice should be avoided. In any case, efforts should be made to place the stents away from the IMA orifice. In patients in whom this is not possible, angiographic evaluation of the superior mesenteric, celiac, and hypogastric arteries is necessary.
The one technical failure in these series was due to severe aortic calcification that precluded complete aortic dilation and resulted in residual stenosis >30%. This patient had undergone a magnetic resonance angiography before being referred to our department for interventional treatment, and we proceeded with aortic stenting and dilation without performing a computed tomography scan. Although the patient benefited from our intervention, because he had clinical and hemodynamic success with improvement of symptoms and ABIs, it should be mentioned that a preoperative computed tomography scan would have been helpful in documenting the amount of calcification and predicting the risk of inability to dilate this aortic lesion.
This study reports successful primary stenting for the whole spectrum of aortic occlusive disease, ranging from isolated aortic stenoses to total chronic aortobiiliac occlusions. Both these lesions were included in the recently published TASC II classification.41 On the basis of excellent technical success rates and long-term outcomes of percutaneous treatment reported by several pioneer groups,14, 15, 16, 34 short focal infrarenal aortic stenosis was placed in the TASC B category, whereas infrarenal aortoiliac occlusion was included in TASC D category according to the latest available data.
The findings of our study are in agreement with the TASC II classification regarding focal aortic stenoses (TASC B), although they also imply a beneficial role of endovascular treatment for chronic total aortoiliac occlusions, which are classified as TASC D and thus considered to be best treated by open surgery. In our opinion, although current evidence supports an open surgical approach to total aortoiliac occlusions, endovascular therapy should not be excluded because it may be appropriate in selected patients.
Conclusion
Our results support the feasibility, safety, and efficacy of primary stenting for stenoses and occlusions of the distal infrarenal aorta. Although larger prospective randomized studies with long-term follow-up are necessary to compare surgery, PTA, and primary stent placement, our preliminary findings along with that of other series indicate that primary stenting may have a significant role in the management of the whole range of infrarenal aortic occlusive disease. Particularly for infrarenal aortic stenoses, it is recommended as the first-line treatment option, whereas for total aortoiliac occlusions, it should be considered as a reasonable alternative to surgery.
Author contributions
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Competition of interest: none.
PII: S0741-5214(07)01614-X
doi:10.1016/j.jvs.2007.10.016
© 2008 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
