James P. Zidar, M.D., F.A.C.C., F.S.C.A.I

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Presentation transcript:

Self-Expanding, Covered or Balloon-Expandable Stenting for Common Iliac Lesions James P. Zidar, M.D., F.A.C.C., F.S.C.A.I Clinical Professor of Medicine UNC Health Systems Corporate Chief of Cardiology, Rex Healthcare President, Rex Heart and Vascular Specialists Raleigh, North Carolina

James P. Zidar, MD Grant Support: Cordis Corporation Honoraria: Medtronic CoreValve Abbott Vascular

Aorto Iliac Lesions Primary and secondary cumulative patency rates at 36 months were 79.4% and 97.7%, respectively. Balloon-expandable stents had a non-significant trend towards higher patency rates compared to self- expanding stents. J Endovasc Ther. 2002 Jun;9(3):363-8

How do you make a diseased iliac artery as normal as possible?

Benefits of Self-Expandable: Distal External Iliac Lesions Flexibility and long lengths, 6 Fr compatible

Iliac Stent Tips: Watch Out for Pseudolesions From Vessel Kinking Real Lesion Fake Stiff guidewire causing pseudolesions Easy to lose track which is the true lesion Left common iliac stented When in doubt, put soft catheter in and inject

Iliac stent options Balloon expandable stents Self-expanding stents Precise placement, approach ipsilateral Best for Common iliac and aortic bifurcation lesions. Excellent radial strength Often need 7 Fr sheath Self-expanding stents Best for long lesions, ectasia, external iliacs. Can approach ipsi- or contra-lateral Can place a 10mm stent in a 6 Fr sheath or 5Fr (Cook) Covered stents Best for ISR, ectasia or perforation. Requires larger 7-10 Fr sheaths.

Iliac case 54 year old smoker with HTN and dyslipidemia Bilateral leg weakness and claudication for 4 mon LE Arterial Duplex suggests severe bilateral inflow disease with minimal SFA-pop disease and 3 vessel runoff ABIs: right .41 and left .53 No CLI No rest pain

Baseline images

Options Send for aorto-bifemoral bypass PTA and Stent left common iliac and send for fem-fem jump graft Attempt to recanalize right iliac and perform bilateral iliac stenting Considerations: Age, functional status, durability, calcium, technical difficulty, patient’s preference

After 8 x 24 mm Genesis stent Location ? Size Length Runoff

Strategies Cross CTO from below Cross from above Kissing balloons at bifurcation ? Size Length

Details 6 Fr 22cm Cordis Britetip sheath in right CFA .035” QuickCross .035” Glidewire Sub-intimal to distal aorta Options?

Details - 2 Advanced .035” Glidewire through Omniflush diag catheter Pulled right sheath back to ext iliac Advanced wire into sheath Externalized wire

Details - 3 Advanced 5.0 x 60mm Fox Plus balloon up R sheath without difficulty and into left ext iliac Pulled wire from L groin and advanced .0035” J wire thru balloon via right groin Advanced a new .035” J wire up L sheath to aorta

Details - 4 Dilate right common iliac with 5 x 60mm Fox Plus balloon What next? Stent BE or SE

Details - 5 Deploy 7 x 59 mm Cordis Genesis stent in R common iliac Protect left common iliac with 7 x 40 mm Fox Plus balloon using kissing inflation

7 x 60 mm Absolute Pro in R EIA and dilate with 6 x 60 Fox Plus balloon to 10 atm

Final

Iliac case: follow-up Seen in clinic 7 months out Quit smoking and gained 10 lb. Only 5’3’‘ and 136 lb. No claudication, occ nocturnal leg cramps Six month LE arterial Duplex notes ABIs of: Right .91, left .92.