Aorta Infrarenal Stenosis: BE, SE or Covered Stents? CRT 2012 Rajesh M. Dave, MD, FACC, FSCAI Chief Medical Executive, Cardiovascular Institute at Ortenzio Heart center, Holy Spirit Hospital Chief, Department of Cardiology Chairman, Cardiac Catheterization Laboratory Camp Hill, PA

Rajesh M. Dave, MD Honoraria Abbott Laboratories Atrium Medical Corporation Cardiovascular Systems Inc. Daiichi Sankyo Bard Peripheral Vascular, Inc. Pathway Medical Technologies, Inc. Abiomed, Inc. Ev3, Inc.

Infrarenal Aortic Lesions: ?PTA Vs Stent PTA feasible: Restenosis in 30% of patients at 5 years 1 Limitations of PTA: risk of distal embolization, embolization of debris, Perforation, Underexpansion of lesions and recoil Stents? Lower Restenosis , Less Recoil Covered2 vs Bare, BE vs SE Cardiovasc Interven Radiol 1989 12:1-6 2. J Vasc Surg. 2011 Dec; 54(6) :1561-70.

Covered Vs Bare: general considerations Covered Advantage: Protection against Perforation and embolization, two most critical complications Covered Disadvantage: Limited size availability in USA (e.g. I-Cast, Fluency, Viabahn, Aortic Cuffs) Bare Stents, Advantages: Many choices, generally smaller sheath sizes Bare disadvantage- Tissue proliferation-higher restenosis rates, especially in TASC C and D Lesions (shown in iliac lesions)

Covered Stents: Access Size and general considerations, Know your choices Icast ( BE Covered): ( Under FDA review for On Label Iliac Indication) -7F sheath compatible ( 10mm can be postdilated to 12mm) -12mm stent 9F sheath ( 12mm stent can be expanded to 22mm) ( Not available in USA, investigational) Fluency(SE covered): (Tracheobronchial indication) Max 10mm diameter -Above 7mmx80mm stent requires 9F or above sheath, can go bareback Viabahn (Iliac Indication, SE Covered): largest 13mm diameter, needs larger than 12F sheath Wallstent Graft; ( SE Covered) ( Billiary): max size

Infrarenal Aortic Lesion : Considerations prior to treatment With or Without Iliac Involvement Calcification: Degree Aneurysmal Vs Non Aneurysmal Disease Ulcerations Total Occlusion- Level Size of Aorta: limited stent sizes in certain cases in USA Relationship to surrounding vessels ie. Renals, Important collaterals etc. Tolerability for access sheath size Availability of IVUS, CTA, MRA

84 yof Severe Claudication and Trash Feet

IVUS is almost Mandatory In my lab, CTA Eccentricity, Calcification

PTA 12mmX 30mm 9mmX59mm ICast

Postdilation by 14mm NC balloon

OUS Case: V12, Large Aorta of 16mm size V12 stent not available for use in USA, investigational device in USA

Aortoiliac Involvement

Problem with Crossing Bilateral Iliac Bare Stents: Avoid!!!

Icast 8mm X 59mm Bilaterally

Conclusions No Randomized trial exists between different stent types Covered stents have significant advantage of Protection against Embolization, Perforation Covered stent: Lower Restenosis Covered BE: Precise Placement, small access sheath sizes, Limitation in current sizes

Conclusions Covered SE: Larger sheath size or open access but larger size available in certain brands BE Bare: Excellent choice for focal non calcified and non thrombotic lesion SE Bare: Easy deployment, large sizes available up to 14mm Bare Disadvantage? Higher restenosis, Higher embolization, perforation

My Personal Strategy Associated aneurysm larger than 4cm or deep penetrating ulcers consider full endograft Smaller than 14mm Aorta BE Covered is my first choice, In future if 12mms BE covered becomes available it will increase options, IVUS is MUST Larger than 14mm aorta, mostly use Endograft Cuffs

Thank you