Management of Aortic and Aortoiliac Stenoses and Occlusions During teh next 15 min I will try to explain my personal point of view, my vision in relation to the role of the cardiologist in the peripheral field. Since I started to work within the EuroPCR, i am trying to bring the cardiologist into ,better back to teh peripheral field. D. Scheinert, MD Center of Vascular Medicine – Angiology and Vascular Surgery Park Hospital Leipzig, Germany

Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Minnow Medical Consultant Lutonix Consultant Atheromed Consultant Angioscore Consultant Cook Medical Consultant Invatec Medtronic Consultant Ev3 Consultant IDEV Techn. Stockholder Abbott Advisory Board Boston Scientific Advisory Board Cordis Advisory Board Novostent Advisory Board Angioslide Advisory Board Gardia Medical Advisory Board Revascular Therapeutics Advisory Board I took this from a presentation at LINC – needs review

Standard Technique for Iliac PTA and Stenting: Retrograde approach

Alternative Technique for Iliac PTA and Stenting: Cross-over approach Preferred technique stenoses and occlusions of the external iliac artery allows multilevel interventions (iliac + femoral) Easier puncture (better pulse)

Chronic Total Occlusion of the left CIA – Recanalization Techniques - Retrograde Approach Brachial Approach Cross-over Approach

Chronic Total Occlusion of the left CIA Retrograde Approach Potential Disadvantages: Difficult puncture Inability to re-enter the true lumen in the area of the aortic bifurcation

Problem of Retrograde Iliac Recanalization

Problem of Retrograde Iliac Recanalization 0.035“ Terumo stiff angled

Often less calcified

Our Experience in Iliac CTO`s: Antegrade recanalization in cross-over or transbrachial technique tends to have the highest success rates!

Occlusion of the right common iliac Retrograde recanalization failed

Cross-over Recanalization Shepherd Hook Hook

Retrograde Stent Implantation

Recanalization of iliac occlusions Patients: n=211 Localization: A. iliaca communis n= 67 31.6 A. iliaca externa n= 74 35.0 Aa. Iliacae comm. et ext. n= 71 33.5 Mean length of occlusion 8.6 cm Technical Success n=190 89.6% Scheinert et al. Am J Med 2001, 110:708-15

Common Iliac Artery Occlusions Preferred Technique: Transbrachial Brachial Approach Left brachial access 6F Sheath 90 cm Recanalization with stiff hydrophilic wire (Terumo)

Transbrachiale Rekanalisation Success rate: 152 of 157 occlusions (96,8%)

Risk of Occluding the Hypogastric Artery After double approach and kissing-stent

Alternative: Retrograd Reca + Outback Failure to renter at the bifurcation

Reentry-Device for Iliac CTOs Outback-catheter

Endovascular Treatment of Aorto-Iliac Occlusions

Endovascular Treatment of Aorto-Iliac Occlusions

Conclusion Interventional recanalization with primary stenting is the first line option for a variety of complex aorto-iliac obstructions incl. occlusions and bifurcation lesions.