1. Rajesh Dave, MD, FACC, FSCAI Harrisburg, PA
Abdominal Iliac Aortic Disease: Choosing the most appropriate stent type
Rajesh Dave, MD, FACC, FSCAI
Harrisburg, PA

2. Disclosures
Grant/ Research/ Consultant: Abbott, Atrium, eV3, Pathway, CSI, Spectranetics, IDEV, Medtronic, Angioslide
This presentation contains off label use of devices and drugs.

3. Aorta Non Occlusive Disease: Ulcer, Aneurysm Aortic Occlusive Disease:
Embolization
Restenosis
Safety

4. 84 yof with Rest pain of both lower extremities

5. Eccentric Calcified
Volcano IVUS

6. 8x40mm Balloon to Predilate
10x38 Icast
Careful where the lowest portion of
Balloon lands, Needs to be above
Bifurcation

7. Post Dilation to 14mm
Final Outcome
No gradient

8. Take Home Messages Aortic Occlusive Disease
Careful Evaluation of Angiography to determine level of disease
Calcification: IVUS is mandatory or CTA
Start with a Low Pressure inflation with Undersized balloon just to allow sheath passing
Upto 14mm Balloon expandable covered stent
Above 14 mm currently SE or Endograft/Cuff

9. Aortoiliac Disease: Stent Choice?
Type A/B: Either BMS or Covered
Type C/D: Calcified, CTO, Complex Ulcerated Disease: Is there a difference?

10. Bx PTFE covered stent iCAST stent
Microporous PTFE covered BX stent
PTFE covers both surfaces
7F/8F system compatible
Available 5-10mm/16-59 mm
Presence of PTFE prevents neo-intimal growth and late restenosis
At 44 month follow up with CTA and vitrea software, stent has shown excellent patency and lack of neointimal growth

11. Long Term Results: Self-Expanding Iliac Stents
Retrospective study of 110 patients with 10 f/u in 109
All had Wallstents placed
Primary patency at 5 years 66%
Primary patency at 10 years 46 %
Secondary patency 79% and 55 %
*SCHÜRMANN et al. RADIOLOGY 2002; 224:731-38

12. SE Non covered: Kissing Stents That Cross
Group
Primary patency
Assisted patency
Non-crossing
94.1%
100%
Crossing
33.2%
45.3%
41 patients (22 men; median age 60.8 years, range 44–86) with kissing stents ( )
Two patient groups
Proximal end of the kissing stents overlapped more than half of their width within the aorta (“crossing” group)
Proximal ends of the stents overlapped half of their width or less (“non-crossing” group)
The primary and assisted primary patency rates at 2 years were significantly different (p=0.01)
Greiner A. et al Does stent overlap influence the patency rate of aortoiliac kissing
stents?. J Endovascular Therapy. 2005; 12: 12

13. Bare metal stent with significant intimal hyperplasia at 12 months

14. Early Failure of Kissing Stents Extending into The Aorta
Rapidly progressive disease proximal or distal to the stents?
Accelerated intimal hyperplasia?
Turbulence leading to thrombosis?

15. Long-Term Results of Combined Femoral Endarterectomy and Iliac Stenting/Stent Grafting for Occlusive Disease Robert Chang, MD, Philip P. Goodney, MD, Jennie H. Baek, BS, Brian W. Nolan, MD, Eva M. Rzucidlo, MD, Richard J. Powell, MD Journal of Vascular Surgery, 2008, Volume 48, Number 2  
Aim:
To report the long term results of patients that underwent combined common femoral endarterectomy and external iliac stenting of TASC C and D lesions using both bare metal stents and stent grafts.
Methods:
171 (22 bilateral) patients who underwent 193 CFA endarterectomies with patch angioplasty and primary stenting in a single combined hybrid open and endovascular procedure for treatment of TASC C and D iliofemoral occlusive disease were retrospectively reviewed.
A variety of stents were used for this procedure, including bare metal SX, bare metal BX, and covered stents including Fluency, Viabahn and iCAST stents.

16. Long-Term Results of Combined Femoral Endarterectomy and Iliac Stenting/Stent Grafting for Occlusive Disease  
Results:
98% Technical success
100% type C and D lesions
Covered stents were used in 41% of cases
Bare metal stents were used in 59% of cases
ABI was increased from 0.38 ± 0.32 to 0.72 ± 0.24 (p <.05)
Patency rates at 5 years:
Primary patency was 60% ± 6%
Primary assisted patency was 97% ± 1%
Secondary patency was 98% ± 2%
Covered stent group showed significantly higher primary patency at 5 years 87% vs. 53% (p<.01)
Conclusion:
Covered stents placed in the iliac position have improved primary patency compared with bare metal stents and may be the preferred device for this patient population.

17. (Covered versus Balloon Expandable Stent Trial)
COBEST TRIAL
(Covered versus Balloon Expandable Stent Trial)
Prof. B. Patrice Mwipatayi
FCS (SA), MMed, FRACS
Royal Perth Hospital, University of Western Australia, Australia
Co-Authors:
Suzanna EL Temple , BSc(Hons) PhD MBA
Shannon D. Thomas, BMedSc Hons MBBS (Hons)
On Behalf of the COBEST Investigators

18. STUDY FLOW CHART COBEST TRIAL PROFILE
Eligible
170 Limbs/R
Excluded – 2 Limbs
Missing data
Analysed – 81 Limbs
Lost to follow-up – 1 Limb
1 Month Limb
6 Months Limb
12 Months Limb
18 Months Limb
V12:
83 Limbs
Lost to follow-up – 6 Limbs
1 Month Limb
6 Months Limb
12 Months Limb
Bare Stent
85 Limbs
Analysed – 80 Limbs
Allocation
Analysis
Follow-Up
Randomised
168 Limbs
(125 Patients)
Enrollment
V12
82 Limbs
86 Limbs
Cross-over

19. Subgroup analysis for binary restenosis
Primary Outcome
Percentage (No)
Odds Ratio
(95% CI)
Risk Difference
V12 Stent
(n = 81)
Bare Stent
(n = 80)
>50% Stenosis
9.8 (8)
24.7 (20)
0.33 (0.13 to 0.83)
-14.9 (-27.7 to )
The Risk of Binary Restenosis by using V12 stents was ↓↓by 67% (95% CI 17% to 87%). The absolute difference was (95% CI -27.7% to -2.1%).

20. Subgroup analysis for occlusions
Primary Outcome
Percentage (No)
Odds Ratio
(95% CI)
Risk Difference
V12 Stent
(n = 81)
Bare Stent
(n = 80)
Occlusion
3.7 (3)
12.35 (10)
0.27 (0.07 to 1.10)
-8.7 (-18.6 to -1.2)
The risk of occlusion by using V12 stents was ↓↓ by 73% (95% CI 7% to 100%).
The absolute difference was -8.7 (95% CI -18.6% to -1.2%).

27. Conclusions For Aortoiliac Occlusive Disease
For Type C/D aortoiliac occlusive disease: Covered BE
Any Crossing Kiss stents: Covered BE
Type A/B: BM BE or SE