1. ICVWG 09-1 Iliac Disease: Core Curriculum

2. ICVWG 09-2 Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

3. ICVWG 09-3 Physical examination –signs of peripheral ischemia –distal embolization –status of the peripheral pulses. Rest and exercise ABI Iliac Disease : Initial Assessment

4. ICVWG 09-4 Iliac Disease: Diagnosis Noninvasive imaging modalities Pressure Gradients Duplex ultrasound (DUS) scans Magnetic resonance angiography (MRA) Computed tomography angiography (CTA)

5. ICVWG 09-5 Pressure Gradients obtained during revascularization of iliac occlusion A. Baseline gradient. B. Gradient after administration of nitroglycerine. C. Postballoon, significant resting gradient remains, evn without provocation. D. Gradient eliminated after stenting, demonstrating superior hemodynamic result. Grossmans “Catheterization” 7 th Ed. pg. 588-592.

6. ICVWG 09-6 Iliac Disease: Duplex Ultrasound DUS has proved to be cost-effective and accurate for the detection of significant vascular stenoses and is therefore often used as the first diagnostic modality. 1, 2 The poor monophasic duplex waveform at the common femoral artery is in itself an accurate marker of aortoiliac obstructive disease. Other waveforms are nondiagnostic for aortoiliac disease. 3 1.Kohler et al Ann vasc surg 1990 (4) 280-287 2.Visser et al Radiology 2000 (16) 67-77 3.Spronk et al J vasc surg 2005; 42(2): 236-242

7. ICVWG 09-7 Three waveform “phases” consisting of a sharp systolic forward up rise and fall, an element of reverse flow during diastole, and an element of forward flow during diastole Triphasic Two waveform “phases” consisting of a sharp systolic forward up rise and fall and an element of reverse flow during diastole One waveform “phase” with a sharp systolic rise, the lack of a reverse diastolic element, and a fast diastolic fall, expected in arterial segments proximal to an obstruction Sharp Monophasic Biphasic : The loss of “sharpness” in systole, the lack of a reverse diastolic element, and a slow diastolic fall expected in arterial segments distal to an obstruction Poor (blunted) monophasic Spronk et al J vasc surg 2005; 42(2): 236-242

8. ICVWG 09-8 Iliac Disease: MR Angiography Enhanced MR angiography showed significant improvement (P <.001) compared with unenhanced MR angiography for diagnosis of clinically significant aortoiliac occlusive disease Rapp et al Radiology 2005; 236: 71-78

9. ICVWG 09-9 Iliac Disease: MR Angiography Transverse reconstruction of a steady-state gadofosveset dataset showing stenoses (arrows) in both right and left common iliac arteries. Gadofosveset-enhanced MR angiography Rapp et al Radiology 2005; 236: 71-78

10. ICVWG 09-10 Iliac Disease: Computed Tomography Angiography CT angiographic examination is less invasive and less expensive than conventional angiography Improves resolution with decreased contrast load and acquisition time without increasing radiation exposure Karcaaltincaba M, Foley D Cardiovasc Interv Rad2005; 28(2): 169-172 A 4-channel MDCT angiogram: Coronal curved planar reformatted images of the abdominal aorta and right iliac artery Rubin et al 2000 Radiology 215: 63-70

11. ICVWG 09-11 Morphological Stratification of Iliac Lesions TASC Type A iliac lesions Single stenosis less than 3 cm of the CIA or EIA (unilateral/bilateral) TASC Type B iliac lesions Single stenosis 3 to 10 cm in length, not extending into the CFA Total of 2 stenosis less than 5 cm long in the CIA and/or EIA and not extending into the CFA Unilateral CIA occlusion ACC/AHA Guidelines

12. ICVWG 09-12 Morphological Stratification of Iliac Lesions TASC Type C iliac lesions Bilateral 5 to 10 cm long stenosis of the CIA and/or EIA, note extending into the CFA Unilateral EIA occlusion not extending into the CFA Unilateral EIA stenosis extending into the CFA Bilateral CIA occlusion TASC Type D iliac lesions Diffuse, multiple unilateral stenosis involving the CIA, EIA and CFA (usually more than 10 cm long) Unilateral occlusion involving both the CIA and EIA Bilateral EIA occlusions Diffuse disease involving the aorta and both iliac arteries Iliac stenosis in a patient with an abdominal aortic anuerysm or other lesion requiring aortic or iliac surgery ACC/AHA Guidelines

13. ICVWG 09-13 Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

14. ICVWG 09-14 Indications for Revascularization Relief of symptomatic lower extremity ischemia, including claudication, rest pain, ulceration or gangrene, or embolization causing blue toe syndrome Grossmans “Catheterization” 7 th Ed. pg. 588-592. Restoration y/o preservation of inflow to the lower extremity in the setting of pre-existing or anticipated distal bypass Procurement of access to more proximal vascular beds for anticipated invasive procedures. Occasionally revascularization is indicated to rescue flow-limiting dissection complicating access for other invasive procedures www.emedicine.com

15. ICVWG 09-15 Iliac artery revascularization before cardiac surgery Significant bilateral disease in order to allow the intra-aortic balloon pump insertion Specific Indications for Revascularization Rigateli et al Internat J Cardiovasc Imag 2002; 22:305-310

16. ICVWG 09-16 Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

17. ICVWG 09-17 Iliac Disease: Angiography Diagnostic aortogram: Inflow and outflow of the target lesion Run-off angiography: Visualization of the lower extremity circulation Transbrachial aortography documents a TransAtlantic Inter-Society Consensus class D iliac occlusion with right external iliac occlusion and complete occlusion of the left iliac system in a 46-year-old man with disabling claudication Leville et al J Vasc Surg 2006; 43(1):32-39

18. ICVWG 09-18 Iliac Disease: Technical Issues Endovascular Access Ipsilateral femoral artery Contralateral femoral artery Brachial artery: In patients with flush occlusions at the aortic bifurcation Multiple access sites may be required for successful treatment: Bilateral femoral Femoral/brachial Leville et al J Vasc Surg 2006; 43(1):32-39 Endovascular recanalization was performed with a hydrophilic guidewire and catheter, and femoral access was obtained with ultrasound guidance

19. ICVWG 09-19 Anticoagulation Aspirin (325 mg) once a day several days prior to the procedure Heparin (2500-5000 IU) after access has been obtained and prior to the intervention Iliac Disease: Technical Issues

20. ICVWG 09-20 Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

21. ICVWG 09-21 Percutaneous transluminal angioplasty (PTA) with or without implantation of a stent is still considered as the gold standard in the treatment of a peripheral lesion. Iliac Artery Disease: Treatment

22. ICVWG 09-22 Endovascular treatment of iliac stenoses –High technical success rates –Low morbidity Iliac PTA/stenting –High rates of patency –Improvement in functional outcome for the individual patient Interventional Management of Iliac Lesions Bosch et al Circulation 1999; 99:3155-3160

23. ICVWG 09-23 Iliac Artery Disease: PTA Iliac Angioplasty: metaanalysis of 2697 procedures before 1990 75% claudicants 2 year primary patency of 81% 5 year primary patency rate 75% Short segment Iliac stenoses: PTA has 5 year 80-90% patency rate Pentacost Circulation 1994 Becker, Radiology 1989

24. ICVWG 09-24 VA Randomized Study: Patients with limited disease suitable for PTA or surgery. Excluding initial PTA failure rate of 15%, 3- year patency of 75% was equivalent in both arms Wilson SE, J Vasc Surg 1989 Swedish Study: Equivalent 1 year results Holm, Eur J Vasc Surgery 1991 Iliac Artery Disease: Surgical vs PTA Randomized Data

25. ICVWG 09-25 Iliac Artery Disease: Stent vs PTA Bosch 1997: meta-analysis of studies between 1990-1997 Stent placement lowered risk of long term failure by 39% Kauffmann 1991: BE stent vs PTA Randomized trial enrolled 131 patients 2 year clinical patency: 89% after stent, 70% after PTA.

26. ICVWG 09-26 Contraindications (Relative) to Iliac Balloon Angioplasty Occlusion Long lesions (>5 cm) Aortoiliac aneurysm Atheroembolic disease Extensive bilateral aortoiliac disease

27. ICVWG 09-27 Iliac Disease: Stent Placement Balloon expandable stent Greater radial force Useful in extremely calcified stenoses and especially occlusions of the common iliac artery Allow greater precision for placement Useful in Ostial Lesions Self-expandable stent Used predominantly in : cross-over techniques and tortuous vessels occlusions of the external iliac artery

28. ICVWG 09-28 JVIR 15:911;2004 Iliac Disease: Stent vs Stent

29. ICVWG 09-29 Interventional Management of Iliac Lesions Type B Currently, endovascular treatment is more often used but insufficient evidence for recommendation Type C Currently, surgery treatment is more often used but insufficient evidence for recommendation Type A Endovascular treatment of choice Type D Surgical treatment of choice Dormandy JA et al J Vasc Surg 2000; 31:S1-S296

30. ICVWG 09-30 Complex long-segment and bilateral iliac occlusions can be safely treated via endovascular means with high rates of symptom resolution. Initial technical success, low morbidity, and mid-term durability are comparable to results with open reconstruction. Interventional Management of Iliac Lesions Leville et al J Vasc Surg 2006; 43(1):32-39 A liberal posture to open femoral artery reconstruction extends the ability to treat diffuse TASC-C and -D lesions via endovascular means.

31. ICVWG 09-31 The Aortoiliac Kissing Stent Technique Reconstructs the aortic bifurcation by simultaneous deployment of bilateral CIA stents The kissing stent technique was developed to avoid complications during PTA of the aortic bifurcation, such as dissection, thrombosis, or significant residual stenosis. Primary placement of kissing stents has been shown to be safe and technically practicable, even in aortoiliac segments with complex atherosclerotic disease. 2 1. Greiner et al, Journal of Endovascular Therapy: Vol. 12, No. 6, pp. 696–703 2. Greiner et al Eur J Vasc Endovasc Surg 2003;26:161–165.

32. ICVWG 09-32 The proximal ends of the stents extend into the aorta such that two adjacent stent walls come into apposition for at least one centimeter in the native aorta Not Stable Stents positioned in this manner reshape the aortic bifurcation more or less anatomically The silhouettes of the right and left stents are marked with black and white lines, respectively. The proximal ends of the bilateral iliac stents extend into the aorta and overlap each other less than half their width “Non-crossing” group

33. ICVWG 09-33 “Crossing” Group The distal end of the stents slip over each other into a crossover position Stable The stents do not really imitate the aortic bifurcation perfectly The silhouettes of the right and left stents are marked with black and white lines, respectively. The proximal ends of the bilateral iliac stents extend into the aorta and overlap each other more than half of their radiologically verified width

34. ICVWG 09-34 Remove the vascular sheath when the activated clotting time (ACT) falls to <160 seconds Continue oral aspirin (325 mg/day) indefinitely / Clopidogrel? Perform ABIs and duplex scanning prior to hospital discharge Follow-up the patient with non - invasive testing to document continued patency. Interventional Management of Iliac Lesions Patient Aftercare

35. ICVWG 09-35 Iliac Disease: surgical Treatment Aortoiliac bypass Aortofemoral bypass PTA Vs surgery –157 iliac lesions was treated with PTA or bypass surgery –No significant difference between PTA or surgery for death, amputations, or loss patency at 3 years –No significant difference in the hemodynamic (ankle-brachial index) result of a successful procedure between the surgery group and the PTA group Wilson et al J Vasc Surg 1989; 9: 1-9

36. ICVWG 09-36 PTA Vs surgery 73% 82% P=0.041 Bar graph of the 3-year event -free survival of PTA Vs surgery for iliac lesions Wilson et al J Vasc Surg 1989; 9: 1-9

37. ICVWG 09-37 Ankle- Barchial Index in Randomized Iliac Lesions BaselinePost-treatment3 year PTA0.50 ± 0.01 0.78 ± 0.04 0.80 ± 0.07 Surgery0.50 ± 0.02 0.82 ± 0.03 0.78 ± 0.05 Wilson et al J Vasc Surg 1989; 9: 1-9 PTA Vs surgery p, ns for all

38. ICVWG 09-38 Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

39. ICVWG 09-39 Iliac Disease: Complications Iliac PTA Note – Numbers are percentages Johnston KW Radiology 1993; 186(1):207-12

40. ICVWG 09-40 Intraoperative complications Dissection Extravasation Perforation Rupture Postoperative complications At the access site: Pseudoaneurysm, atrioventricular fistula Distal embolization Hematoma Stent thrombosis Systemic complications (<0.5%): Contrast or atheroembolic induced renal failure, MI, CVA, death Iliac Disease: Complications

41. ICVWG 09-41 Iliac Disease: Perforation

42. ICVWG 09-42 Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

43. ICVWG 09-43 Hypertension Hypercholesterolemia Poor tibial runoff Clinical status: Critical limb ischemia Smoking, Diabetes mellitus Female gender Vessel diameter < 8mm Outflow status Lack of antiplatelet regimen Number of stents Occlusion vs. stenosis Iliac Disease: Predictors of long-term failure Grossmans “Catheterization” 7 th Ed. pg. 588-592.

44. ICVWG 09-44 Iliac Disease: Favorable predictors Short, focal lesion Large vessel size Common iliac (as opposed to external iliac) Single lesion ( as oppsosed to multiple serial lesions) Male gender Lesser Rutherford category (Claudication as opposed to critical limb ischemia) Presence of good runoff Grossmans “Catheterization” 7 th Ed. pg. 588-592.

45. ICVWG 09-45 Ideal Iliac PTA Lesions Stenotic lesion Non-calcified Discrete (< 3cm) Patent run – off vessels (> 2) Non- diabetic patients Grossmans “Catheterization” 7 th Ed. pg. 588-592.

46. ICVWG 09-46 Iliac Disease: Comparison of 3 year Results Severity/Site/Variable 3 year Success rate Iliac Occlusion 1 site 66 % † > 1 site 17 % † Iliac Stenosis Common iliac 68 % ‡ External iliac Men 57 % † Women 34 % † Both common and external Good runoff 73 % † Poor runoff 30 % † † Cox regression estimate ‡ Kaplan-Meier Johnston KW Radiology 1993; 186(1):207-12

47. ICVWG 09-47 Patency after iliac PTA by Clinical and Lesion variables 1 year %3 year %5 year % ST/CL/GR817063 ST/LS/GR654838 OC/CL/PR614333 OC/LS/PR561710 CL, claudication; GR, good run-off; LS, limb-threatening ischemia; OC, occlusion; PR, poor run-off; ST, stenosis Johnston et al Semin Vasc Surgery 1989; 3:117-22

48. ICVWG 09-48 PatientsTechniqueFollow-upPrimary Patency Secondary Patency Tegtmeyer 1991200PTA7.5 yrs85%92% Palmaz 1992486BE stent2 yrs92% Strecker 1993114SE stent3 yrs95% Henry 1995184BE stent4 yrs86% Murphy 199583BE stent2 yrs87.5% Martin 1995140SE stent2 yrs71%86% Vorwerk 1996109SE stent4 yrs82%91% Schurmann 2002110SE stent10 yrs46%55% (50%mortality) Gaines 2005116BE stent6 months82.7& Leville 200689SE/BE stents 3 yrs76 90 Iliac Artery Revascularization: Stenoses

49. ICVWG 09-49 Long-term success Primary and subsequent endovascular procedures for iliac lesions in 151 limbs Kudo et al J Vasc Surg 2005; 42 (3):466.e1-466.e13

50. ICVWG 09-50 Endovascular Treatment of Symptomatic Iliac Occlusions Leville et al J Vasc Surg 2006; 43(1):32-39

51. ICVWG 09-51 Iliac Disease:Outcomes Kaplan-Meier curve estimates for primary patency, secondary patency, and limb salvage in all patients treated for iliac occlusion over 36 months. Primary patency was 76%, secondary patency was 90%, and limb salvage was 97% at 36 months with an SE less than 10%. Leville et al J Vasc Surg 2006; 43(1):32-39

52. ICVWG 09-52 Iliac Disease: Primary Patency Kaplan-Meier curve estimates for primary patency in patients treated for iliac occlusion stratified by TransAtlantic Inter-Society Consensus (TASC) level over 36 months. No significant difference was found between groups. *SE exceeded 10%. Leville et al J Vasc Surg 2006; 43(1):32-39

53. ICVWG 09-53 Iliac Disease: Secondary Patency Kaplan-Meier curve estimates for secondary patency in patients treated for iliac occlusion according to TransAtlantic Inter-Society Consensus (TASC) stratification. There was no significant difference between groups, and patency was greater than 90% for patients with type B and C iliac occlusions. *SE exceeded 10%. Leville et al J Vasc Surg 2006; 43(1):32-39

54. ICVWG 09-54 PatientsTechniqueFollow-upPrimary Patency Secondary Patency Vorwerk 1995103stents4 yrs78%88% Henry 2000155stents8 yrs73%86% Scheinert 2001212BE/SE/ covered 4 yrs76%85% Mouanoutoua 2003 50stents2 yrs93%86% Balzer 2005 43Excimer laser BE/SE/ covered 4 yrs86.1%95.4% Iliac Artery Revascularization: Occlusions