Chapter 108 - Aortoiliac disease endovascular treatment Flashcards
Balloon angioplasty was developed by
Dotter and Gruntzig
Threshold for significant systolic gradients
Resting systolic > 10 mmHg Vasodilator-enhanced gradient > 20 mmHg
Relative contraindication to endovascular treatment of AIOD
1) juxtarenal aortic occlusion 2) circumferential calcification >1mm 3) hypoplastic aortic syndrome 4) juxtaposition to aneurysmal disease 5) renal insufficiency
Definition of contrast induced nephropathy
Increase in Cr > 25% or > 44.2 increase within 3 days of contrast in absence of alternative cause
How long does it take for contrast induced nephropathy to return to baseline
14 days
Concerns of contrast induced nephropathy in terms of baseline GFR
eGFR > 60 rare 40-45 concerned < 30 very concerned
Key points on the risk of contrast induced nephropathy and dosing
1) Precaution for eGFR < 60 in IA admin 2) precaution for eGFR < 45 in IV admin 3) keep total volume < 5ml/kg 4) second dose within 48 hours increase risk (should wait 72 hours) 5) withhold diuretics on day of contrast injection
Number needed to treat with sodium bicarb to prevent contrast induced nephropathy
8.4 patients
Number needed to treat with acetylcysteine to prevent contrast induced nephropathy
no evidence that it works
Sodium bicarbonate bolus and infusion to prevent contrast induced nephropathy
Bolus 3 ml/kg/hr (154 mEq/L NaHCO3 in dextrose and water) for 1 hour before contrast then at 1 ml/kg/hr during contrast use and another 6 hours after
Dose of vasodilator for measuring significant lesions
Nitroglycerin 100-200 mcg Papaverine 25 mg
Maximum increase in pressure gradient occurs this much time after injection of vasodilator
20-40 seconds
Describe outback reentry catheter
LuMend Inc 1) single lumen 2) retractable needle to gain access
Describe Pioneer catheter
Medtronic 1) IVUS
Techniques to recanalize CTO in iliac
1) contralateral 2) brachial 3) reentry wire/catheters
Amount of stent oversizing in iliac artery
5-10%
Measurement of treatment success after stenting iliac artery
<20% residual stenosis <10 mmHg systolic pressure gradient
Benefit of balloon-expandable stent/grafts
1) precision of placement 2) high radiopacity 3) high hoop strength
Benefit of self-expanding stent/graft
1) flexible
Iliac POBA patency
44-65% 4 years
Complication of iliac angioplasty
1) dissection 2) closure 3) spasm 4) thrombus formation 5) embolization
Patency of kissing iliac stents (primary and secondary)
78% primary 98% secondary
Dutch iliac stent trial study group
1) POBA +/- stent vs primary stent 2) 43% in POBA group got stented 3) no difference between the two groups 4) reintervention ~20%
Metaanalysis on primary stenting vs selective stenting
1) 1300 patients 2) technically success > 90% with primary stenting 3) primary patency > 70% at 2-5 years with stenting 4) 4 year patency in claudicant 68% POBA vs 77% stent 5) 4 year patency in CLTI 55% POBA vs 67% stent
Murphy long term results 18 studies on iliac stenting or plasty
1) tech success 97% 2) complication rate 6% 3) 5 year primary patency 73%; secondary 85%
Schurmann 10 year follow up iliac stenting
1) primary patency 66% at 5 years; 46% at 10 years 2) secondary patency 79% at 5 years; 55% at 10 years 3) restenosis 41% in 3.9 years
When and why should metformin be held to avoid contrast induced nephropathy
1) 48 hours 2) lactic acidosis rare complication can worsen AKI
Galaria on 10 year patency with TASC lesion classes A+B
1) 77% claudicants 2) 62% TASC A, 38% TASC B 3) mortality 1.8% 30 days; 4.7% 90 days 4) complication 7% 5) hemodynamic success 82% (ABI > 0.15) 6) primary patency 71% 10 years 7) two vessel femoral runoff or 2+ tibial vessel improved patency 8) limb salvage rate 95% 5 years and 87% 10 years
de Vries and Hunink Metaanalysis on iliac stent patency 1970-1996
Claudication: 5 year 91%; 10 year 86.8% CLTI: 5 year 88%; 10 year 82%
Primary patency for TASC C+D with endo
60-86% 5 year
Secondary patency for TASC C+D with endo
80-98% 5 year
Successful recanalization in TASC C+D iliac lesions
90%
Hybrid femoral treatment and iliac endo 5 year patency
Primary: 60% Primary assisted 97% Secondary 98%
Stent graft vs bare stents in iliac disease patency
87% vs 53%
1 year patency in EIA disease with bare stent
47%
Predictors of bad outcome in iliac stenting
1) female 2) renal insufficiency 3) CLTI
Primary patency at 6 and 12 months in patients treated with iliac endo alone vs those with FEA as well
FEA + iliac plasty 94% 6 months; 94% 12 months iliac plasty alone 79% 6 months; 53% 12 months
Primary patency at 3 and 5 year for iliac stent graft
80% at 3 and 5 years primary patency 95% primary assisted patency at 3 and 5 years
Primary patency in TASC lesion in iliac stent graft
TASC B: 100% 5 year patency TASC C: 61% TASC D: 85%
COBEST trial
1) Mwipatayl et al 2) bare metal vs stent graft in AIOD 3) 5 year patency TASC C+D: 50% stent vs 95% graft 4) TASC B no difference
all cause mortality in claudicants at 5, 10, 15 years
30% - 5 years 50% - 10 years 70% - 15 years
Cause of death in PAD patients
40-60% CAD 10-20% CVA 10% other vascular causes (mainly ruptured aneurysm) 20-30% non-vascular (mainly cancer)
Schumann et al mortality at 5 and 10 years following iliac stenting
17% at 5 year 36% at 10 years
Local complication rate in iliac stent
1-3%
Rate of arterial rupture in iliac stent
<1%
recommended follow up after iliac plasty
1 month then 6 months
Restenosis on duplex as a measure from peak systolic velocity
Doubling of peak systolic velocity = restenosis
Aortoiliac lesions
TASC classifications
