Michael S. Segal1, Sameh Elrabie1, and Rajesh K. Malik2 1 Department of General Surgery, Wyckoff Heights Medical Center, Brooklyn, NY, USA 2 Division of Vascular Surgery, Wyckoff Heights Medical Center, Brooklyn, NY, USA Obtaining computed tomographic angiography (CTA) improves preprocedural planning for aortoiliac disease. Planning should include anticipating any potential pitfalls and including potential bailout options in the plan. Access should be obtained dependent on the lesion location determined from preprocedural imaging and may require multiple sites of access. Shorter, less complex lesions are best treated with a self‐expandable stent. Longer, complex, calcified lesions are better treated with covered stents and protect against potential rupture during deployment. If you require precise deployment, then consider using a balloon‐expandable stent. Preprocedural planning and imaging is key to performing successful aortoiliac interventions. This workup begins with diagnostic studies to assess the disease location, extent of disease, calcifications, and gain an appreciation for potential pitfalls that may be encountered during therapeutic intervention [1]. Appropriate preprocedural workup can reduce contrast load for the patient, radiation exposure to the provider, and improve safety and success rates. Computed tomographic angiography (CTA) has become the most utilized imaging modality for preoperative planning. A CTA provides substantial information, including potential access‐related issues, length and complexity of the lesion, extent of calcifications, and the size of the vessels. This essential information can help minimize procedure‐related complications by helping formulate a safe strategy to treat. We strongly recommend obtaining CTA imaging prior to interventions (Figure 8.1). Figure 8.1 A 3D reconstruction of CTA imaging demonstrating extensive calcifications and an occluded left iliac artery. Ultrasound (US) is another imaging modality that can be used in the initial part of the workup, however, from a practical standpoint, is limited in its utility for aortoiliac interventions. This is secondary to being user dependent and limited by patient habitus above the inguinal ligament. Additionally, bowel gas patterns can limit the utility of US. An exercise ankle‐brachial index may be more helpful if there is suspicion of a proximal lesion. Magnetic resonance angiography is not routinely used in our practice as there is no benefit over CTA, which is easier to obtain and, in our view, provides much more useful information. Angiography is rarely used in planning unless a CTA or MRA was not able to be performed. During angiography, morphologic characteristics of the diseased segments and pressure gradients can be measured to assess questionable iliac lesions. A pressure gradient of 20 mmHg or greater is considered significant [2]. In our practice, aortoiliac angiogram is performed with the intention to treat, unless the disease encountered is not amenable to endovascular intervention. TASC A and B lesions were amenable to endovascular interventions with positive outcomes and patency rates. Historically, TASC C and D lesions were treated with open surgical intervention. As endovascular interventions have improved, increasingly complex lesions are being approached endovascularly. TASC C and D lesions can now be treated endovascularly with patency rates approaching surgical patency rates [3] (Figure 8.2). After the imaging has been reviewed, a treatment plan should be formulated. This plan should include the location of the access and the basic equipment that needs to be used during the procedure, including wires, balloons, and various stents. It is important to have appropriate bailout equipment available should a complication be encountered. This includes having larger sheaths available, covered stents, and an aortic occlusion balloon. Aortoiliac interventions are best performed with light sedation. This is important because significant pain during the intervention, such as ballooning the artery, may indicate that the artery is stretching beyond its threshold and could risk rupture. Figure 8.2 TASC II classifications for aortoiliac occlusive disease. In planning aortoiliac interventions, access site selection is an important consideration. Options for access include femoral, brachial, or radial arteries. Radial access is an up‐and‐coming option but still slightly limited by equipment lengths, although that is changing rapidly. Terumo® makes a 6 Fr 119 cm R2P Destination slender sheath® with a 5 Fr outer diameter. Through this a self‐expandable stent, up to 8 mm, can be deployed to the iliac arteries. In our practice, we typically use either femoral or brachial artery access, occasionally requiring multiple access sites. The location of the lesion and anatomic factors will ultimately determine which access site is preferable [2]. Access site selection is determined by the location of the lesion. A common iliac lesion is treated from the ipsilateral common femoral artery (CFA) or brachial artery. An external iliac lesion is treated from the contralateral CFA or brachial artery. If the lesion is in the proximal portion of the external iliac artery, an ipsilateral approach can be considered. Multiple access sites may be necessary when treating more complex lesions extending up to and including the infrarenal aorta. In these cases, bilateral femoral artery access or a combined brachial and femoral access can be utilized. There are considerations for access to reduce complications. Access is performed under US guidance. When performing brachial access and utilizing a larger sheath, 6 Fr or greater, particularly in women, we recommend a cutdown to minimize complications. That seems to be the cutoff size based on our personal experience. Sheath selection through which the intervention is done is an important consideration for the procedure. For ipsilateral interventions of the common iliac artery, a 7 Fr radio‐opaque Brite‐Tip® sheath is our ideal selection. The Brite‐Tip sheath or another marker tipped sheath aids in visualization of the sheath tip so that a stent is not inadvertently deployed within the sheath. This sheath is large enough to facilitate the balloon and stent sizes for the iliac artery, including the larger covered stents that are utilized as bailout options if needed. A 23 cm sheath length works well as it can be used to cross the lesion and facilitate delivery of a balloon‐mounted stent without the stent dismounting off the balloon. If access from the contralateral groin is needed for an up and over approach, a 6 or 7 Fr long sheath will suffice.
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Aorto‐Iliac Interventions
Introduction
Preoperative Workup
Noninvasive Studies
Computed Tomographic Angiography
Ultrasound Duplex
Magnetic Resonance Angiography
Invasive Imaging
Angiography
Classification of Lesion and Planning of Intervention
TransAtlantic InterSociety Consensus II Classification (TASC II)
Planning for the Intervention
Step 1. Patient Factors
Step 2. Vascular Access
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