Percutaneous Reconstruction of the Aortoiliac Bifurcation

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Presentation transcript:

Percutaneous Reconstruction of the Aortoiliac Bifurcation Presented by: Amit Nanavati, MD Cardiology Fellow Authors: Amit Nanavati, MD, Sarang Mangalmurti, MD, Bryan Kluck, DO No disclosures

Case Presentation 49 year-old female with dyslipidemia (LDL 207) presents with gangrene of the left second toe (Rutherford 5). MRA demonstrated infrarenal aortic occlusion with reconstitution prior to the aortoiliac bifurcation with significant right common iliac disease and fair distal flow (TASC D lesion).

Left - Initial aortogram demonstrating infrarenal aortic occlusion with distal reconstitution prior to the aortoiliac junction. Significant proximal right common iliac disease also seen. Center – An angled glidewire was advanced into the left common iliac artery through the 90 cm left brachial sheath and percutaneous transluminal angioplasty (PTA) of the distal aorta was performed. Right - Little change in flow was noted after PTA. A flap was noted at the origin of the right common iliac

Left – Right femoral artery access was obtained and a wire exteriorized through the left brachial sheath Center – Simultaneous self expanding bare metal stents were deployed in the distal aorta into each the left and right common iliac, effectively recreating the aortoiliac bifurcation. Distinct stenosis is noted in the left common iliac artery. Right – Balloon expansion of the stents to improve flow

Left – Intravascular Ultrasound confirms tissue prolapse in the left common iliac artery. PTA was performed to this region. Right – Final result demonstrating brisk flow with patent stents and no focal obstructions

Discussion Indications for reconstruction stenting can include infrarenal aortic disease (crossing configuration) or significant iliac disease (abutting configuration) Persp in Vasc Surg and Endovasc Ther 2008, 20(1): 50-60

Comparison with Surgery Ann Vasc Surg 2010 24: 4-13

Previous Studies 173 consecutive patients (41% with TASC D lesions) were studied with 1% 30 day mortality Stent type did not influence patency Patency rate similar regardless of complexity of lesion From European Journal of Vascular and Endovascular Surgery Volume 36, Issue 4 2008 424 - 431

Discussion Access site as well as distal embolization are the primary complications (3.5% vs. 8-13% OR rate) Geometric mismatch may affect patency rates: Aggressive disease, graft problems From Annals of Vascular Surgery Volume 22, Issue 3 2008 346 - 357

Conclusion Traditional aortobifemoral bypass may be undesirable in younger patients and consideration should be given to percutaneous intervention, which has good outcomes Contact Information: Amit Nanavati Cardiology Fellow Lehigh Valley Health Network Allentown, PA Amit_N.Nanavati@lvh.com