1. Interventional Treatment of obstructive aortoiliac disease Dr Afshin Ghofraniha Interventional Cardiologist

2. Endovascular treatment of Coarctation 5-8 % of all congenital heart disease The first angioplasty of Coa 1981( POBA for recoarctation ) The first stent 1991 Endovascular treatment : A)Balloon angioplasty 1: One balloon technique (no greater than aortic diameter at diaphragmatic level ) 2 : Two balloon kissing technique(lower profile sheaths)

3. Endovascular treatment of Coarctation B / Stenting : 1 : Balloon expandable stents 2 : Self expandable stents 3 : Stent grafts ( less risk of rupture, dissection,and pseudoaneurysm) a/ PDA and Coa b/very narrow segment c/ prior surgical conduit

4. Case presentation A 43 y old male with long history of HTN Ph ex : weak pulses in lower limbs Echo :LVH,EF = 60% CT angio : Coarctation of aorta just after left subclavian artery Treatment Plan : Surgery V Intervention Key Points: 1/ How many arterial lines 2/How to puncture 3/Which type of stents

5. Angiography (aortic interruption)

7. Two orthogonal views

10. Puncture with stiff end of Terumo 0.035 wire

12. Mullins sheath entering proximal aorta

13. Spring wire

14. Predilation with balloon 3-80

15. Sheath 12 in the occlusion

17. CP covered stent+BIB (18-45)

18. Inner balloon inflation

19. outer balloon inflation

20. Final results

22. Aortoiliac obstructive disease The Trans Atlantic Inter-sociaty Consensus is the major classification in approaching obstructions of abdominal aorta and proximal iliac arteries TASC 2 (2007 ) recommends endovascular treatment for TASC A&B while surgery is the treatment option for TASC C&D lesions

23. TASC Classification

24. Endovascular strategy in treating obstructive aortoiliac disease Bare Stents Strategy : A / Common funnel technique : 1/One balloon expandable or self expandable stent in proximal limb of conduit and putting two kissing BES as flow dividers and extension of distals by BES or SES B /New carina formation(high origin bifurcation reconstriction )by two kissing BES and then extension of distal limbs by BES or SES

25. Covered stents Strategy: A /CERAB technique: Proximal limb by a large BES followed by two kissing BES(making a AAA like endograft at aortic bifurcation ) B/ High origin of aorticbifurcation by two kissing BES and extension to distals by multiple covered BES At the moment no place for covered SES in aortoiliac occlusive disease

26. Case presentation A 36 year old man presenting with severe rest pain on lower limbs ( more on left side )for few days Past HX : He is a known case of PVD since 5 years (aortoiliac occlusion underwent aortoiliac bypass ) Risk Factors : Diabetes for many years, smoking,addiction to opiods Physical exam : No pulses,coldness on both limbs,pain on distalls and some mottling

27. Occlusion starting just after renal arteries

28. Distal cannulation by roadmap

31. Subintimal path

32. Very hard job to reconnect three subintimal spaces

33. Reconnection on right side

34. Reconnection on left side

35. Wire snaring

36. Now two wires from femorals into abdominal aorta

37. Deployment of common proximal stent

38. Deployment of two balloon expandable stents in common funnel

39. Completing the extensions

41. Final results

43. Case presentation 64 y old man with claudication in lower limbs for 8 years At the time of referral he was in Rutherford class 4 Ph ex : No palpable pulses in lower extremities Past Hx : Smoking, HTN, PCI on LAD, Hypercholestrolemia CTA findings : CTO of distal abdominal aorta with long distance from renals CTO of both common iliacs Right limb of occlusion 7.5 cm and left limb 5.5cm Moderate calcification of CTO segment Distal perfusion of iliacs through mesenteric collaterals

46. Left limb reconnection

48. Wire snaring into guiding catheter

49. Sub intimal path in right side

51. Puncture by stiff end of terumo wire

53. Right wire snaring

54. Complete both side wiring

55. A new carina formation by two kissing balloon expandable stents

57. Distal extensions

59. Final results