advanced techniques for recanalization of tasc c/d ... · tasc 2007 recommendations for aortoiliac...
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Advanced techniques for recanalization of TASC C/D aortoiliac lesions
Sven Bräunlich, MD Department of Interventional Angiology University Hospital Leipzig, Germany
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Disclosure
Speaker name: Sven Bräunlich I have the following potential conflicts of interest to report: Consulting: Abbott, Biotronik, Cook Medical, Cordis, Covidien, CR Bard, Medtronic, Straub Medical
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TASC 2007 recommendations for aortoiliac lesions
TASC A
TASC B
TASC C
TASC D
≤ 3 cm
≤ 3 cm CIA-occlusion
unilateral 3 – 10 cm No extension
into CFA
3 – 10 cm bilateral
No extension into CFA Involvement of IIA
Diffuse disease aorta or CFA involved
PTA 1. choice
Surgery 1. choice
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Is NOT this... The answer for this...
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Imaging – DSA Early
Preconditions for endo approach:
Patent proximal aorta
Patent CFA
Late
Endovascular Treatment of Aorto-Iliac Occlusions
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Start with brachial access
Allows for imaging
Ideal coaxial alignment of the sheath
Much easier recanalization than femoral
Direct orthograde access to the occlusion
Technique for Aorto-Iliac Occlusion PTA
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Why crossing from brachial?
Problem of retrograde iliac recanalization: • Inability to re-enter the true lumen in the area of the aortic bifurcation
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Why crossing from brachial?
Often less calcified
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Endovascular Treatment of Aorto-Iliac Occlusions
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Krankenberg et al, Clin Res Cardiol 2009
Prospective Study, n=11 (8 male, 2003 - 2007), - ABI 0.4 ± 0.08 - Impotence 4/8
Bilateral reconstruction: 8 / 11 (72,7 %) Unilateral reconstruction: 3 / 11 ( 27,3 %) • 1 fem-fem crossover bypass • 1 acute stent occlusion managed by thrombolysis
Endovascular reconstruction of the aortic bifurcation in patients with
Leriche-syndrome
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Krankenberg et al. Clin Res Cardiol 2009
Clinical follow-up after 1 year: • ABI: 0.79 ± 0.20 (vs. 0.48 ± 0.08 at baseline, p=0.0004)
• Rutherford 1 7/11 • Rutherford 2 4/11 Primary Patency (n=7), CT 100%
Endovascular reconstruction of the aortic bifurcation in patients with
Leriche-syndrome
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Schmalstieg et al. J Cardiovasc Surg. 2012
- Prospective registry, n=20 (2003 - 2012),
- Bilateral reconstruction: 17/ 20 (85 %) - Unilateral reconstruction: 3/ 20 (15 %)
- 1 fem-fem. crossover bypass after acute stent occlusion
Long-term data of endovascular treatment of complex aorto-iliac occlusions
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Follow-up after 3 years (Median 37 months): • ABI (n= 18) 0,48 -> 0,86 • Clinical presentation: Rutherford class 1: 13
Rutherford class 2: 4 Rutherford class 5: 1
Schmalstieg et al. J Cardiovasc Surg. 2012
Long-term data of endovascular treatment of complex aorto-iliac occlusions
• TLR (Target lesion revascularisation) 10% 1 Bypass (after unilateral reconstruction) 1 Bypass (after acute stent occlusion)
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Endovascular Recanalization of an Aortic Occlusion
64 years, male • Ultra short walking distance • Rest pain at night Medical history: • CAD, CABG • EF 40% • COPD
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Complication: Acute stent thrombosis:
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Elective angiography after 6 weeks
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Implantation of covered stents
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Protection of visceral arteries
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- 25 Patients with aortoiliac occlusions - January 2010 – August 2014 - Technical success rate 100 % - Mean Age 58.8 years - Claudicatio intermittens 35 /50 - Critical ischemia 15 /50
Leipzig Experience of Endovascular Therapy of Aorto-Iliac Occlusions with Covered Stents
- Follow-up 10.2 Months (1-49) - Repeat Revascularization 3 Patients (12%)
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Potential causes of restenosis after stent-reconstruction of the aortic bifurcation
Saker et al. Early failure of kissing stents. JVIR 2000
Formation of - Thrombus - Mesenchymal tissue - Hyperplasia arround and within the stents
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COBEST-Trial: Covered vs.
non-covered stents
Randomized multicentric,
- 83 patients Advanta V12 (covered)
- 84 patients BMS (balloon-, selfexpanding)
Primary endpoint: - Restenosis after 12, 18 months
(Duplex, CTA, DSA)
P. Mwipatayi et al. J Vasc Surg 2012
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Log Rank (Mantel-Cox) P < .002
P. Mwipatayi et al. J Vasc Surg 2012
Freedom from binary restenosis of Iliac TASC C and D lesions
V-12 (covered)
Non-covered
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Coral Reef Syndrome: better surgery ?
Massive aortic calcification
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PTA for Coral Reef Syndrome
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Endovascular Therapy of Infrarenal Aortic Occlusions
• Technically feasible, minimally invasive
• Covered stents are required • So far only limited long-term data available
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Endovascular Therapy of Infrarenal Aortic Occlusions
• Thank you!
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Stentgrafts for reconstruction of aorto-iliac occlusions ?
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Schenkelverschluss 3 Tage nach Implant. Fogarty
Zusätzlliche Implantation von
Balloon-exp. Stents
Stentgrafts for reconstruction of aorto-iliac occlusions ?
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Covered stents for reconstruction of the aorto-iliac bifurcation
Goverde et al. LINC 2011