Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty

PURPOSE: The purpose of this study was to explore the feasibility of iliofemoral endarterectomy performed through a single groin incision. METHODS: Thirty-two patients aged 34 to 75 years (mean age 63.4 years) with a male/female ratio of 20:12 underwent 36 lower extremity inflow reconstructions from July 1989 to September 1994. Surgical indications were for limb-threatening ischemia in 24 patients and for claudication in eight patients. The procedures were done for occlusive disease of the external iliac artery and common femoral artery with patients under either spinal (n = 24) or local (n = 12) anesthesia. Intraoperative balloon angioplasty with fluoroscopic guidance preceded open retrograde iliofemoral endarterectomy. Adjunctive procedures included 18 profundaplasties, eight femorofemoral, nine femoropopliteal, and one femorotibial bypasses. RESULTS: Thirty-three of the 36 cases were initially successful. The three failures were in patients with extensive calcification. The mean follow-up has been 36.4 months, and the patency rate was 80.5% at 3 and 4 years. The four failures noted on follow-up were caused by three common iliac artery stenoses and one iliac system occlusion. The former group was successfully treated with balloon angioplasty/stent, and the latter patient required an aortofemoral bypass. No operative deaths or limb loss occurred in this series. CONCLUSIONS: Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty is a safe, easy-to-perform, and viable option for patients with combined external iliac artery and common femoral artery occlusive disease. Midterm results (36.4 months) are favorable, and most hemodynamic failures are easy to correct with standard endovascular techniques.     

Lower-extremity arterial endovascular stenting

Intraluminal arterial stenting for the management of arterial occlusive disease of the lower extremities has evolved over the years. Most stents are used to correct inadequacies of PTA or to correct a PTA complication. These include (1) restenosis within 90 days of PTA, (2) chronic iliac occlusion, (3) acute occlusions during PTA, (4) a significant residual gradient following PTA, (5) dissections longer than the angioplasty site, and (6) a 30% or greater residual stenosis after PTA. Both the Palmaz stent and the Wallstent have performed well in the iliac artery system. Their use in the femoropopliteal system has not been as successful and should be reserved for selected cases. Long-term anticoagulation is generally required for femoropopliteal stent patency. Placement in the lower superficial femoral or popliteal artery is best avoided. Re-angioplasty or additional stenting may be used to prolong patency, although with the risk of a second intervention. Progression of arteriosclerosis is a factor to consider when choosing an endoluminal treatment versus standard bypass.     

Combination endovascular and open treatment of peripheral arterial occlusive disease performed by surgeons

The endovascular treatment of peripheral arterial occlusive disease has historically been performed by interventional radiologists and cardiologists. With additional training in endovascular techniques, surgeons become uniquely suited to manage arterial lesions with both endovascular and conventional surgical techniques. Over a 14-month period, 13 patients underwent combination endovascular and open reconstruction on limbs with peripheral arterial occlusive disease. There were 10 males and 3 females. The mean age was 66 years. All procedures were performed in the operating room by surgery residents under the direct supervision of vascular surgeons. After intraoperative angiography, 26 arterial lesions underwent percutaneous transluminal angioplasty (aorta, 1; common iliac, 14; external iliac, 10; superficial femoral, 1). Twenty-five of 26 lesions were further treated with intraluminal stent placement, the lone exception being a case of superficial femoral artery angioplasty. Concomitant open reconstruction was performed on all limbs, 14 as outflow and 1 as inflow. There were two cases of procedural morbidity and one perioperative death secondary to myocardial infarction. There were no wound-related complications. The mean ankle-brachial index of the affected lower extremity improved from 0.41 (+/- 0.15) to 0.74 (+/- 0.14) at 30 days. Mean follow-up was 8 months (range, 2-14). Based on our early experience, simultaneous combination endovascular and open reconstruction of multisegment arterial occlusive disease can be performed safely and efficiently by surgeons.     

Percutaneous transluminal angioplasty for the treatment of limb threatening ischemia: do the results justify an attempt before bypass grafting?

PURPOSE: Results of percutaneous transluminal angioplasty (PTA) in selected cases have been reported to be equal or superior to those of arterial bypass graft surgery, with a lower morbidity and mortality. We performed PTA of stenotic or occlusive lesions in patients with limb-threatening ischemia, hoping to improve our overall success and decrease morbidity in this group of patients. The results of PTA in the limb-salvage setting was evaluated. METHODS: From 1992 to 1995, 307 PTAs were performed in 257 patients. One hundred sixty-one (63%) patients had diabetes mellitus, and 32 (12%) patients had renal failure. All patients were evaluated by means of pulse volume recordings and ankle brachial indices at 1 and 6 weeks after PTA and at 3 month intervals thereafter. Seventeen patients (9%) were lost to follow-up. The continued success or failure of PTA was defined by means of noninvasive vascular laboratory criteria, patency by means of pulse examination, the need for subsequent bypass grafting across the index lesion, and limb salvage. RESULTS: The 1-year patency rates for external iliac PTAs (56%) were significantly lower (P <.05) than those for common iliac PTAs (87%). Infrainguinal PTAs at the femoral, popliteal, and tibial level had 1-year patency rates of less than 15%. CONCLUSION: Common iliac artery PTA is justified in most cases in which it is feasible. However, when PTAs are performed below the inguinal ligament, the results are markedly worse. One-year patency rates of PTA in this group of patients with threatened limbs are inferior to the patency rates of arterial bypass grafts, even when these bypasses are performed with a prosthetic material. PTA should not be considered as a primary treatment modality for patients with infrainguinal arterial occlusive disease who also have limb-threatening ischemia, except in unusual circumstances.     

Randomised comparison of primary stent placement versus primary angioplasty followed by selective stent placement in patients with iliac-artery occlusive disease. Dutch Iliac Stent Trial Study Group

BACKGROUND: Percutaneous transluminal angioplasty (PTA) is a safe, simple, and successful treatment for intermittent claudication caused by iliac-artery occlusive disease. Primary stent placement has been proposed as more effective than PTA. We compared the technical results and clinical outcomes of two treatment strategies-primary placement of a stent across the stenotic segment of the iliac artery, or primary PTA followed by selective stent placement when haemodynamic results were inadequate. METHODS: We randomly assigned 279 patients with intermittent claudication, recruited from departments of vascular surgery, either to direct stent placement (group I, n=143) or primary angioplasty (group II, n=136), with subsequent stent placement in case of a residual mean pressure gradient greater than 10 mm Hg across the treated site. The main inclusion criterion was intermittent claudication on the basis of iliac-artery stenosis of more than 50%, proven by angiography. All patients had a clinical assessment before intervention and at 3, 12, and 24 months. Clinical success was defined as improvement of at least one clinical category. Secondary endpoints were initial technical results, procedural complications, cumulative patency as assessed by duplex ultrasonography, and quality of life. FINDINGS: In group II, selective stent placement was done in 59 (43%) of the 136 patients. The mean follow-up was 9.3 months (range 3-24). Initial haemodynamic success and complication rates were 119 (81%) of 149 limbs and 6 (4%) of 143 limbs (group I) versus 103 (82%) of 126 limbs and 10 (7%) of 136 limbs (group II), respectively. Clinical success rates at 2 years were 29 (78%) of 37 patients and 26 (77%) of 34 patients in groups I and II, respectively (p=0.6); however, 43% and 35% of the patients, respectively, still had symptoms. Quality of life improved significantly after intervention (p<0.05) but we found no difference between the groups during follow-up. 2-year cumulative patency rates were similar at 71% versus 70% (p=0.2), respectively, as were reintervention rates at 7% versus 4%, respectively (95% CI -2% to 9%). INTERPRETATION: There were no substantial differences in technical results and clinical outcomes of the two treatment strategies both at short-term and long-term follow-up. Since angioplasty followed by selective stent placement is less expensive than direct placement of a stent, the former seems to be the treatment of choice for lifestyle-limiting intermittent claudication caused by iliac artery occlusive disease.     

Multicenter investigation of coronary stenting to treat acute or threatened closure after percutaneous transluminal coronary angioplasty: clinical and angiographic outcomes

OBJECTIVES: This study reports on the initial experience with the Gianturco-Roubin flexible coronary stent. The immediate and 6-month efficacy of the device and the incidence of the complications of death, myocardial infarction, emergency coronary artery bypass surgery and recurrent ischemic events are presented. BACKGROUND: Abrupt or threatened vessel closure after coronary angioplasty is associated with increased risk of myocardial infarction, emergency coronary artery bypass graft surgery and in-hospital death. When dissection or prolapse of dilated plaque into the lumen is unresponsive to additional or prolonged balloon catheter inflation, coronary stenting offers a nonsurgical mechanical means to rapidly restore stable vessel geometry and adequate coronary blood flow. METHODS: From September 1988 through June 1991, 518 patients underwent attempted coronary stenting with the 20-mm long Gianturco-Roubin coronary stent for acute or threatened vessel closure after angioplasty. In 494 patients, one or more stents were deployed. Thirty-two percent of patients received stents for acute closure and 69% for threatened closure. RESULTS: Successful deployment was achieved in 95.4% of patients. Overall, stenting resulted in an immediate angiographic improvement in the diameter stenosis from 63 +/- 25% before stenting to 15 +/- 14% after stenting. Emergency coronary artery bypass graft surgery was required in 4.3% (21 of 493 patients). The incidence of in-hospital myocardial infarction (Q wave and non-Q wave) was 5.5% (27 of 493 patients). At 6 months, myocardial infarction was infrequent, occurring in 1.6% (8 of 493 patients). The incidence of in-hospital death was 2.2% (11 of 493 patients). Late death occurred in 7 patients (1.4%) and 34 patients (6.9%) required later bypass graft surgery. Complications included blood loss, primarily from the arterial access site, and subacute thrombosis of the stented vessel in 43 patients (8.7%). CONCLUSIONS: The early multicenter experience suggests that this stent is a useful adjunct to coronary angioplasty to prevent or minimize complications associated with flow-limiting coronary artery dissections previously correctable only by surgery. Although this study was not randomized, it demonstrated a high technical success rate and encouraging results with respect to the low incidence of emergency coronary artery bypass graft surgery and myocardial infarction.     

Single dose medication vial packaging deficiencies

OBJECTIVES: Technical success and early outcome of modified surgical techniques integrating interventional procedures for iliac recanalisation performed through an incision in the groin. MATERIALS: Sixty-one consecutive iliac arteries in 59 patients with long occlusions in 16, occlusions of the common iliac in 11, occlusions of the external iliac in 24 and multiple stenoses of the iliac in 10 cases underwent semiclosed recanalisation through a groin incision. METHODS: Passage of the lesion by guidewire permits retrograde ring-stripper endarterectomy over the wire as a guiding splint or thrombectomy with a double lumen balloon catheter. Residual lesions are corrected by balloon or stent angioplasty. Adequate outflow is established by femoral patch plasty. RESULTS: Conversion to a standard operation was required in 10 limbs (failure to recanalise the lesion in nine, rupture after angioplasty in one). Initial technical success was achieved in the remaining 51 limbs (recanalisation by ring stripper endarterectomy in 36, thrombectomy in 14, both in six, additional intraoperative angioplasty in 42). Five postoperative thromboses were successfully treated by a combined surgical and interventional approach accounting for a 1-month 100% secondary patency. CONCLUSION: Iliac recanalisation through the groin by modified ring stripper endarterectomy or modified thrombectomy in combination with intraoperative angioplasty is a safe and effective procedure. Long-term results are required to evaluate the procedure.     

Contemporary management of isolated iliac aneurysms

OBJECTIVE: Because isolated common iliac artery aneurysms are infrequent, are difficult to detect and treat, and have traditionally been associated with high operative mortality rates in reported series, we analyzed the outcomes of operative repair of 31 isolated common iliac artery aneurysms in 21 patients to ascertain morbidity and mortality rates with contemporary techniques of repair. METHODS: A retrospective review study was conducted in a university teaching hospital and a Department of Veterans Affairs Medical Center. Perioperative mortality and operative morbidity rates were examined in 17 men and four women with isolated common iliac artery aneurysms between 1984 and 1997. Ages ranged from 38 to 87 years (mean 69 +/- 8 years). Slightly more than half of the cases were symptomatic, with abdominal pain, neurologic, claudicative, genitourinary, or hemodynamic symptoms. One aneurysm had ruptured and one was infected. There was one iliac artery-iliac vein fistula. All aneurysms involved the common iliac artery. Coexistent unilateral or bilateral external iliac aneurysms were present in four patients; there were three accompanying internal iliac aneurysms. Overall, 52% of patients had unilateral aneurysms and 48% had bilateral aneurysms. Aneurysms ranged in maximal diameter from 2.5 to 12 cm (mean 5.6 +/- 2 cm). No patients were unavailable for follow-up, which averaged 5.5 years. RESULTS: Nineteen patients underwent direct operative repair of isolated iliac aneurysms. One patient had placement of an endoluminal covered stent graft; another patient at high risk had percutaneous placement of coils within the aneurysm to occlude it in conjunction with a femorofemoral bypass graft. Patients with bilateral aneurysms underwent aortoiliac or aortofemoral interposition grafts, whereas unilateral aneurysms were managed with local interposition grafts. There were no deaths in the perioperative period. Only one elective operation (5%) resulted in a significant complication, compartment syndrome requiring fasciotomy. The patient treated with the covered stent required femorofemoral bypass when the stent occluded 1 week after the operation. The patient treated with coil occlusion of a large common iliac aneurysm died 2 years later when the aneurysm ruptured. CONCLUSIONS: Isolated iliac artery aneurysms can be managed with much lower mortality and morbidity rates than aneurysm previously been reported by using a systematic operative approach. Percutaneous techniques may be less durable and effective than direct surgical repair.     

Results of peripheral endovascular procedures in the operating room

PURPOSE: This study presents the results of closed (percutaneous) and open endovascular procedures performed exclusively by vascular surgeons in the operating room and compares them with results from combined series from the literature, including primarily closed procedures in radiology or cardiology facilities. METHODS: Retrospective review of 607 consecutive peripheral arterial and venous angioplasties, stents, thrombolytic cases, and inferior vena caval filters in 446 patients was analyzed for immediate success rate, complication rate, and 1-year life table patency rate. RESULTS: The incidence of initial technical success was: aorta, 89%; iliac artery, 91%; superficial femoral artery, 90%; popliteal artery, 91%; tibial arteries, 79%; arm arteries and veins, 86%; renal arteries, 100%; IVC filters, 98%; and iliofemoral veins, 100%. The 1-year primary patency rates, including technical failures, were 70.3% in 113 femoropopliteal procedures and 83.7% in 194 iliac arteries. Advantages to the use of the operating room included: (1) simultaneous angioplasty during a bypass operation for abnormalities proximal or distal to the graft, (2) correction of lesions first discovered during thrombectomy, and (3) optimum patient monitoring and sedation in the operating room. CONCLUSIONS: Endovascular procedures performed by vascular surgeons in the operating room lead to results comparable with procedures performed in nonsurgical interventional suites, and the use of the operating room has advantages.     

Reversal of proinflammatory responses by ligating the macrophage Fcgamma receptor type I

OBJECTIVE: The purpose of the study was to evaluate the use of renal artery stents in the solitary functioning kidney of patients who have impaired renal function as a result of atherosclerotic renovascular disease by assessing primary patency, renal function outcome, and complication rates during a mean follow-up period of 15 months. MATERIALS AND METHODS: The Palmaz stent was placed in the arteries of 21 patients with solitary functioning kidneys. All patients had impaired renal function (creatinine level >150 micromol/l), and four patients were undergoing renal dialysis. Indications for stenting were recoil after percutaneous transluminal angioplasty (n = 12), arterial dissection after angioplasty (n = 2), restenosis after angioplasty (n = 1), and as the primary intervention (n = 6). Follow-up angiography was performed in 16 patients (76%). RESULTS: Initial technical success was achieved in all patients (residual stenosis, <5%). At follow-up (range, 6-25 months), renal function had returned to normal in five patients (24%), improved in four patients (19%), stabilized in six patients (29%), and deteriorated in six patients (29%). Dialysis has been discontinued in all four dialysis patients. Major complications occurred in four patients (19%), including one death within 30 days of stenting. No significant restenoses were seen on follow-up angiography. CONCLUSION: Placement of renal artery stents in the solitary kidney led to benefits in 70% of patients treated, including improved renal function in nine patients (43%) and stabilization in six patients (29%). In this high-risk group of patients, we advocate renal artery stenting as a relatively safe procedure to salvage the solitary kidney.     

Quantitative detection of Sphingomonas chlorophenolica in soil via competitive polymerase chain reaction

PURPOSE: To develop an ex vivo human carotid artery stenting model that can be used for the quantitative analysis of risk for embolization associated with balloon angioplasty and stenting and to correlate this risk with lesion characteristics to define lesions suitable for balloon angioplasty and stenting. METHODS: Specimens of carotid plaque (n = 24) were obtained circumferentially intact from patients undergoing standard carotid endarterectomy. Carotid lesions were prospectively characterized on the basis of angiographic and duplex findings before endarterectomy and clinical findings. Specimens were encased in a polytetrafluoroethylene wrap and mounted in a flow chamber that allowed access for endovascular procedures and observations. Balloon angioplasty and stenting were performed under fluoroscopic guidance with either a Palmaz stent or a Wallstent endoprosthesis. Ex vivo angiograms were obtained before and after intervention. Effluent from each specimen was filtered for released embolic particles, which were microscopically examined, counted, and correlated with various plaque characteristics by means of multivariate analysis. RESULTS: Balloon angioplasty and stenting produced embolic particles that consisted of atherosclerotic debris, organized thrombus, and calcified material. The number of embolic particles detected after balloon angioplasty and stenting was not related to preoperative symptoms, sex, plaque ulceration or calcification, or artery size. However, echolucent plaques generated a higher number of particles compared with echogenic plaques (p < 0.01). In addition, increased lesion stenosis also significantly correlated with the total number of particles produced by balloon angioplasty and stenting (r = 0.55). Multivariate analysis revealed that these two characteristics were independent risk factors. CONCLUSIONS: Echolucent plaques and plaques with stenosis > or = 90% produced a higher number of embolic particles and therefore may be less suitable for balloon angioplasty and stenting. This ex vivo model can be used to identify high-risk lesions for balloon angioplasty and stenting and can aid in the evaluation of new devices being considered for carotid balloon angioplasty and stenting.     

The placebo in modern medicine

PURPOSE: To report the results of balloon angioplasty in recurrent carotid occlusive disease and evaluate the potential for stent implantation. METHODS AND RESULTS: Between April 1991 and September 1995, 15 patients with carotid restenosis underwent 17 endoluminal procedures in 3 common carotid and 14 internal carotid arteries. Two postdilation complications (dissection and acute occlusion) required prompt stenting; one common carotid artery was stented for postdilation residual stenosis. One recurrent lesion was also stented 6 months after initial angioplasty. One stroke, 1 silent cerebral infarction, and 3 transient ischemic attacks occurred in the balloon angioplasty patients (33% neurological complication rate). The common carotid stent patient died 3 days postoperatively due to hyperperfusion syndrome. Long-term follow-up in two stent patients showed no restenosis at 18 and 48 months, respectively. The 11 balloon angioplasty patients likewise have not demonstrated restenosis. CONCLUSIONS: Balloon angioplasty alone appears too risky for treating recurrent carotid disease. Stents may offer a safer alternative, particularly when implanted primarily.     

Femoro-femoral crossover bypass in monolateral obstructions of the iliac artery

The Authors report the result of their ten-years experience with femoro-femoral crossover bypass in 26 patients affected with unilateral occlusion of the iliac artery. This bypass is an easy and quick procedure, useful in both short and long term. The patency rate after 58 months is 84.6%. Thus, its use indicated in a high number of patients, not only for a limb salvage treatment of a disabling claudication. The indications for this bypass can be extended to low surgical risk subjects, and it does not have to be considered only for the high-risk patients, instead of major surgery procedure on the aorto-iliac axis. The minimal necessary conditions of the limbs for performing the femoro-femoral crossover bypass are a pressure gradient of 35 mmHg and the angiographical demonstration of the unilateral occlusion. If the contralateral axis appears patent, but there are also multiple atherosclerotic sites, we consider other bypasses as therapeutical choices: aorto-bifemoral, ilio-femoral and the femoro-femoral cross-over itself; in the latter case we previously perform a transluminal angioplasty or an endarterectomy of the donor iliac artery. In these situations is essential to evaluate of the benefit/risk rate for every single patient.     

Aortoiliac stent deployment versus surgical reconstruction: analysis of outcome and cost

PURPOSE: The purpose of this study is to compare complication rate, primary patency, and cost of stent deployment with direct surgical reconstruction for the treatment of severe aortoiliac occlusive disease. METHODS: From March 1, 1992, to May 31, 1996, 119 patients receiving treatment for aortoiliac occlusive disease were analyzed after exclusions. Sixty-five patients had stent deployment and 54 patients had surgical reconstruction. Data were evaluated within and between the groups by univariate and multivariate logistic regression, life-table, t-test, and cross tabulation with chi2 analysis. RESULTS: There was no significant difference between the groups with regard to demographic features or presenting symptoms (all p values > 0.07). Incidence of procedure-related complications was similar (p = 0.30). However, there were more systemic complications in the surgery group (15 versus 2; RR = 5.5, p < 0.01) and more vascular complications in the stent group (16 versus 3; RR = 12, p < 0.002). Incidence and type of late complications were not appreciably different (all p values > 0.05). Cumulative primary patency rate of bypass grafts was significantly better than stented iliac arteries at 18 months (93% versus 77%), 30 months (93% versus 68%) and 42 months (93% versus 68%); p = 0.002, log rank. Multivariate analysis identified female gender (RR = 4.6, p = 0.03), ipsilateral SFA occlusion (RR = 5.6, p = 0.01), procedure-related vascular complication (RR = 9.7, p = 0.002), and hypercholesterolemia (RR = 5.0, p = 0.02) as independent predictors of bypass graft or stent thrombosis. Mean total hospital cost per limb treated did not differ significantly between surgery and stent deployment groups ($9383 versus $8626, respectively; p = 0.66, t-test). CONCLUSIONS: Treatment of severe aortoiliac occlusive disease by surgical reconstruction or stent deployment has a similar complication rate. Mean hospital cost per limb treated is essentially equal. However, cumulative primary patency rate of bypass grafts is superior to stents. Therefore, considering the elements of cost and patency, surgical revascularization has greater value. The benchmark for cost-effective treatment of severe aortoiliac occlusive disease is direct surgical reconstruction.     

Long-term angiographic and clinical outcome of patients undergoing multivessel coronary stenting

BACKGROUND: Randomized clinical trials have shown that multivessel coronary angioplasty is feasible and provides similar long-term survival as bypass surgery in selected patients. However, the higher need for repeat intervention, in particular, coronary artery bypass graft surgery, remains a problem. The objective of this study was to test the hypothesis that multivessel stenting is safe and effective in reducing the need for repeat interventions, in particular, the need for bypass surgery. METHODS AND RESULTS: Between March 1993 and June 1995, 100 consecutive patients (243 lesions) had multivessel coronary stenting. High-pressure stent optimization was used in all patients. Procedural success was achieved in 97% of lesions; 2 patients (2%) required emergency bypass surgery. Angiographic follow-up was obtained in 89% of patients at 5.2+/-2.5 months. Angiographic restenosis occurred in 22% of the lesions, but 37% of patients had > or = 1 lesion with restenosis. Clinical follow-up was obtained in all patients at 21 +/- 10 months: target lesion revascularization was needed in 30 patients (30%), repeat angioplasty in 28 patients (28%) and coronary bypass surgery in 2 patients (2%); the overall survival rate was 96% (2% noncardiac death). CONCLUSIONS: Multivessel coronary stenting can be performed with high success rate and low need for emergency bypass surgery. Compared with historical results with multivessel percutaneous transluminal coronary angioplasty, patients who undergo multivessel stenting need less repeat interventions, in particular, less coronary bypass surgery and have similar long-term survival.     

Percutaneous transluminal angioplasty of iliac occlusions

Percutaneous transluminal angioplasty (PTA) has become an established treatment modality for iliac artery stenosis. PTA of iliac artery occlusions, however, remains a topic of controversy due to difficulties with mechanical recanalization, a lower patency rate and a higher complication rate than obtained after PTA of iliac artery stenosis. During a three year period, we performed 31 PTA's of iliac artery occlusions. The primary recanalization rate was 71% (22 occlusions). Stents were applied in 16 patients. The cumulated patency rates were 95% and 85% after one and six months respectively. There was one late reocclusion after two years. We found a tendency towards inferior patency in the longer occlusions (> or = 5cm). The complication rate was 10% due to three episodes of distal embolisation, all of which were successfully treated immediately with additional PTA and stenting. These results are in accordance with the results of international studies, and suggest that PTA is a useful alternative to surgical treatment of iliac artery occlusions, albeit long occlusions involving both the common and the external iliac artery should be excluded.     

The force/time relationship of clinically used sensory testing instruments

Aortoiliac occlusive disease is a significant cause of lower extremity ischemic symptoms. Over the past two decades, most patients have been treated with a variety of surgical procedures, including aortofemoral and extra-anatomic bypasses. Most recently, percutaneous balloon angioplasty and stents have been successfully used for the treatment of limited iliac lesions. New endovascular grafts that combine vascular grafts with stents in a device with new characteristics may allow the successful treatment of patients with extensive aortoiliac occlusive disease in a less invasive fashion. In our early experience, the endovascular grafts were constructed with Palmaz balloon-expandable stents and standard polytetrafluoroethylene (PTFE) grafts. The 18-month primary and secondary patency rates were 89% and 100%, respectively, with a limb salvage rate of 94%. Endovascular grafts can be successfully used to treat patients with extensive aortoiliac occlusive disease, with excellent early results. Long-term results and further graft improvements will define their role in the treatment of patients with aortoiliac occlusive disease.     

Transluminal balloon angioplasty, stents, and atherectomy

Arterial bypass grafting for occlusive disease is still considered the gold standard in the treatment of arterial occlusive disease. However, less invasive methods are available for select patients. Percutaneous balloon angioplasty has been shown to be effective in focal iliac artery stenosis, with patency rates of 50% to 90% at 5 years. Patency rates for femoropopliteal lesions are generally less than 50% at 2 years. Complications seen with balloon angioplasty often can be treated with arterial stents. Stents can be categorized into balloon-expandable, which provide a rigid scaffold to support the artery, self-expanding, which exert radial force to resist external compression, and thermal expanding stents, which allow for the use of a smaller introducer sheath. Another treatment option is atherectomy, in which the offending lesion is removed instead of fracturing and dilating the lumen. Although overall initial results of atherectomy have not been favorable, short lesions with eccentric atheroma or intimal hyperplasia, such as those seen in dialysis access fistulas or vein graft stenoses, may respond well.     

Intraarterial pressure gradients after randomized angioplasty or stenting of iliac artery lesions. Dutch Iliac Stent Trial Study Group

PURPOSE: To determine initial technical results of percutaneous transluminal angioplasty (PTA) and stent procedures in the iliac artery, mean intraarterial pressure gradients were recorded before and after each procedure. METHODS: We randomly assigned 213 patients with typical intermittent claudication to primary stent placement (n = 107) or primary PTA (n = 106), with subsequent stenting in the case of a residual mean pressure gradient of > 10 mmHg (n = 45). Eligibility criteria included angiographic iliac artery stenosis (> 50% diameter reduction) and/or a peak systolic velocity ratio > 2.5 on duplex examination. Mean intraarterial pressures were simultaneously recorded above and below the lesion, at rest and also during vasodilatation in the case of a resting gradient < or = 10 mmHg. RESULTS: Pressure gradients in the primary stent group were 14.9 +/- 10.4 mmHg before and 2.9 +/- 3.5 mmHg after stenting. Pressure gradients in the primary PTA group were 17.3 +/- 11.3 mmHg pre-PTA, 4.2 +/- 5.4 mmHg post-PTA, and 2.5 +/- 2.8 mmHg after selective stenting. Compared with primary stent placement, PTA plus selective stent placement avoided application of a stent in 63% (86/137) of cases, resulting in a considerable cost saving. CONCLUSION: Technical results of primary stenting and PTA plus selective stenting are similar in terms of residual pressure gradients.     

Endovascular stent graft repair for aneurysms on the descending thoracic aorta

BACKGROUND: The traditional treatment of aneurysms of the descending thoracic aorta includes posterolateral thoracotomy and aortic replacement with a prosthetic graft. In this study, we report our experiences and results in endovascular stent graft placement as an alternative to surgical repair. METHODS: Between January 1989 and July 1997, a total of 68 patients (24 women) underwent replacement of the thoracic aorta. Mean age at operation was 51 years. Fifty-eight patients underwent conventional surgical treatment. All of these patients were suitable candidates for endovascular stenting; however, no stent graft material was available at the time of operation. Ten patients (1 chronic dissection, 9 atherosclerotic aneurysm) received in the past 8 months the first commercially manufactured endovascular stent graft. The mean diameter of the aneurysms in this group was 7 cm (range, 6 to 8 cm). Two stent patients were operated on using only spinal cord analgesia. All stent grafts were custom designed for each of the 10 patients. RESULTS: The 30-day mortality in the conventional group was 31% versus 10% in the stent group. Mean length of intervention was 320 minutes in the conventional group versus 150 minutes in the endovascular group. Spinal cord injury occurred in 5 patients (12%) in the surgical group, whereas none of the stented patients developed any neurologic sequelae. Mean intensive care unit stay was 13 days, followed by a mean of 10 days on a ward in the first group compared to 4 days in the intensive care unit and 6 days on the ward in the stent group. One stent was required in 2 patients, two stents were required in 3 patients, and four stents were deployed in 5 patients of our series. Five patients required transposition of the left subclavian artery to achieve a sufficient neck for the proximal placement of the stent. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent graft in 8 patients (80%). Two patients required restenting as a result of leakage (20%). Stent graft placing was performed through the femoral artery in 8 patients, whereas access was only achieved through the abdominal aorta in 2 patients. CONCLUSIONS: These preliminary results demonstrate that endovascular stent graft replacement might be a promising, cheaper, and safe alternative method in selected patients with descending thoracic aneurysms.