1. Division of Endovascular Interventions Mount Sinai Hospital New York 07/31/2019

2. Patient history
71 year old female patient, presents with LLE claudication (buttock, thigh and calf). Rutherford class 3
PMH: active smoker, HTN and HLD.
Medication: aspirin, atorvastatin, lisinopril.

3. Non-invasive Imaging CT-angiogram LE Arterial Duplex:
Right: atherosclerotic plaque, no significant stenosis
Left: atherosclerotic plaque with blunted wave forms suggestive of severe external  iliac disease.
CT-angiogram

4. Iliac artery revascularization

5. Indication for revascularization ACC/AHA Guidelines
Gerhard-Herman et al. JACC 2017;e

6. Appropriate use criteria Aorto-Iliac PVI
Klein AJ et al. Catheter Cardiovasc Interv. 2017;90(4):E90-E110.

7. Appropriate use criteria Aorto-Iliac PVI
Klein AJ et al. Catheter Cardiovasc Interv. 2017;90(4):E90-E110.

8. Technical considerations
Access:
Bilateral femoral artery
Radial/brachial artery
Angiographic views: contralateral oblique to better visualize the bifurcation (external and internal iliac artery)
Sheath: minimum of 7Fr. Length 25cm
Anticoagulation: preferred heparin, but bivalirudin is associated with similar outcomes*. ACT
* Sheikh, JACC int vol 2;

9. Lesion crossing Non-occlusive lesion: Occlusive lesion:
Hydrophilic-coated glide wire
Angled support catheter
Occlusive lesion:
Hydrophilic coated and specialty wires (0.014 or 0.018)
Microcatheter
Exchange for more supportive 0.35 wire after crossing the lesion

10. Adjunctive crossing/re-entry devices for iliac CTO
Crossing devices:
Frontrunner, Viance, Ocelot
Re-entry devices
Outback, Offroad, Pioneer

11. Intravascular imaging
IVUS:
Calcium distribution
MLA
Vessel size
JACC Intv 2015;8:1893–901

12. PTA: Important rules to follow
Use initially nominally undersized balloon
To avoid perforations, dissections
To assess the degree of calcification
Slow and sequential upsizing of balloons is recommended
Avoid additional balloon expansion with onset of abdominal pain

13. Plaque modification:
Cutting or scoring balloons are mainly used for cases of ISR
Intravascular lithotripsy

14. Stent selection Self expanding stent (SE)
Balloon expanding stents (BE)
Covered stents SE BE

15. Pros and cons Device Advantages Disadvantages BE
High radial strength (optimal for CIA, calcified lesion)
Precise deployment
Higher propensity of edge dissection/perforation
Higher likelihood of plaque shift to the contralateral SE
High flexibility
Low risk of perforation
Low radial strength
Not suitable for precise deployment
Cannot be post-dilated beyond their designated diameter
Covered
Excludes aneurysms
Prevents neointimal growth in the stent lumen
Excludes side branches
Higher likelihood of edge restenosis

16. BE vs. SE ICE trial Inclusion criteria RF 1-4
single significant (>=70% diameter stenosis or occlusion by DUS) CIA or EIA lesion of mm in length, not extending into the aorta or the common femoral artery.
Comparison:
BE (Visi-Pro, ev3 Endovascular, Inc., Plymouth, Minnesota)
SE (Protege, ev3 Endovascular, Inc.)
Primary endpoint:
binary restenosis at 12 months (PSVR>=3.4 by DUS).
Primary patency
Freedom from TLR
Independent predictors of restenosis
JACC Intv 2017;10:1694–1704

17. Jaff MR. SCAI 2012. Las Vegas, NV
MOBILITY: Modern Endovascular Management of Patients with Iliac Artery Disease
PAD with high prevalence of calcification and multilevel disease
SE: Absolute Pro vs. BE: Omnilink Elite stenting systems
(Abbott Vascular, Santa Clara, CA).
9-Month Follow-up
Absolute Pro
(n = 151 pts, 181 lesions)
Omnilink Elite
(n = 153 pts, 203 lesions)
Major Adverse Events
6.1%
5.4%
Restenosis
8.4%
9.0%
Freedom from TLR
97.1%
94.9%
Functional improvements were noted in walking distance and speed as well as in stair climbing (P < for all endpoints vs. baseline).
Jaff MR. SCAI Las Vegas, NV

18. Covered vs. non-covered stent
COBEST trial
Patients with aortoiliac occlusive disease
- Inclusion criteria
Men and women aged >18 years
Informed consent obtained
Evidence of TASC B, C, or D lesions
Hemodynamically significant dissections and recurrent stenosis after angioplasty
- Comparison:
CS Advanta V12 balloon-expandable covered stent (Atrium Medical Corp, Hudson, NH)
BE commercially available BMS
- Primary endpoint:
Freedom from binary restenosis (defined as >50% reduction in lumen diameter) or stent occlusion by DUS, CTA or 18 months
J Vasc Surg 2011;54:

19. 18 months FUP
J Vasc Surg 2011;54:

20. COBEST @ 5-years FUP Primary patency Secondary patency
Predictors of primary patency
J Vasc Surg 2016;64:83-94.

21. Summary
Endovascular iliac artery interventions are increasing including more complex lesions (TASC C and D)
Careful case selection, work-up and planning is mandatory to achieve maximum success
Despite the reported safety of bivalirudin, heparin is preferred AC
Various stents are available for different lesion subsets with favorable long-term outcomes

22. Thank you