Abstract
Concomitant stenosis and aneurysmal disease in the iliac artery lumen are a rare finding. Surgery has been the modality of choice for this degree of complexity; however, advancement in techniques, evolution of stent grafts and increasing operator experience have made endovascular intervention a feasible option. TransAtlantic InterSociety Classification (TASC) categorizes the presence of iliac stenosis adjacent to iliac aneurysm as the most severe category for aortoiliac lesions or a TASC II D lesion. The 2014 Society of Cardiovascular Angiography and Interventions (SCAI) expert consensus statement advocated endovascular approach for TASC II A, B and C lesions with a trend to favor endovascular approach for TASC II D lesions as well. If surgery is not an option or is refused, covered stent provides a viable option due to its ability to treat severe atherosclerotic disease and exclude the aneurysmal lumen at the same time. We here describe a case of a patient with Rutherford II (4) claudication symptoms who was found to have bilateral iliac artery stenosis with adjacent co-existing aneurysmal disease. After surgical intervention was refused, endovascular repair was performed with multiple Gore Viabahn covered stents with resolution of symptoms and good angiographic results.
Highlights
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64 year old man with Rutherford Grade II (4) claudication symptoms
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Angiography demonstrated the presence of iliac aneurysm adjacent to iliac stenosis.
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TASC categorizes this complexity as a TASC II D lesion.
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Successful endovascular management with VIABAHN® Endoprosthesis
1
Introduction
Common Iliac Artery Aneurysms (CIAAs) are defined as CIA diameter > 2.0 cm and are predominantly seen in males with a mean age around 70 years. Most CIAAs are incidentally found along with co-existing abdominal aortic aneurysms (AAAs) with the incidence of isolated CIAAs at a mere 2%–8%. The TransAtlantic InterSociety Classification (TASC) is used to determine severity of peripheral arterial disease (PAD) depending on anatomic distribution, number and nature of lesion. TASC categorizes the presence of aortic or iliac aneurysm adjacent to stenosis as TASC D lesions. The advancement in endovascular techniques has made it a feasible approach even in TASC C and D lesions . The Society of Cardiovascular Angiography and Interventions (SCAI) consensus statement for aortoiliac interventions released in 2014 bestows confidence in endovascular management of TASC D lesions in the hands of experienced operators . However, presence of aneurysmal disease with underlying severe symptomatic PAD presents a unique challenge. As surgical management for iliac aneurysms has traditionally been associated with high morbidity and mortality, the availability of covered stents to exclude the aneurysmal lumen provides an attractive minimally invasive option. We here describe a case where symptomatic atherosclerotic iliac artery disease with co-existing common iliac artery (CIA) aneurysm was successfully treated with VIABAHN® Endoprosthesis (W.L. Gore and Associates, Flagstaff, AZ).
2
Case description
A 64 year old man with history of coronary artery disease, hypertension and diabetes presented to clinic with Rutherford Grade II (4) claudication symptoms. Baseline ankle-brachial indexes (ABIs) were (0.73) on right and (0.77) on left lower extremity. Computed Tomography angiography (CTA) showed the infrarenal abdominal aorta measuring a maximum diameter of 3.8 cm, right common iliac artery with aneurysm measuring at 2.5 cm with large mural thrombus, severe stenosis of distal common iliac and proximal external iliac artery and an occluded right internal iliac artery ( Fig. 1 a ). Left common iliac artery had moderate disease extending diffusely throughout its entire course and mild stenosis at the origin of left external iliac artery ( Fig. 1 b). Patient was given an option for surgery versus endovascular approach and he opted for the latter.
The procedure was performed in an inpatient setting under local anesthesia in addition to moderate sedation. Both the femoral arteries were accessed under ultrasound guidance using modified Seldinger technique. The left femoral artery was accessed first followed by introduction of 5-Fr sheath. 5-Fr Omni flush catheter was used along with Bentson Wire (Cook Medical) to access the distal aorta and aortography was performed ( Fig. 2 ). This was followed by right femoral artery access with a 5-Fr sheath which was later upsized to a 7-Fr sheath. We initially crossed the right iliac artery lesion using soft angled Glide wire (Terumo Interventional Systems) and then exchanged the Glide wire for Amplatz super stiff wire (Boston Scientific).
Balloon angioplasty of right external iliac artery (EIA) was performed using 6 × 40 Mustang Balloon (Boston Scientific), followed by deployment of 8 × 100 Viabahn stent (Gore Medical) in the right CIA extending up to the right EIA. The size and length of the graft were determined by the proximal and distal reference vessel diameter measured during both CTA and invasive angiography. As per the reference diameter measurements, 8 mm diameter was thought to be adequate for the right iliac artery and 9 mm diameter for left iliac artery ( Fig. 2 ). However, we underestimated the length of right iliac lesion and had to deploy two 8 × 50 mm stents to cover the proximal and distal lesion adequately ( Fig. 3 ). All 3 stents were dilated with 8 × 100 Mustang balloon. After completion of right iliac artery endovascular revascularization, the left femoral artery sheath was upsized to 9 Fr sheath after placement of super stiff Amplatz wire. As seen in the Fig. 3 , there was adequate landing zone for both iliac stents proximally and distally. This was followed by deployment of a 9 × 50 Viabahn stent in left CIA covering the ectatic segment. Stent was post dilated with 9 × 50 Mustang Balloon. Left EIA had 50%–60% residual disease which was not intervened to preserve left IIA. Post-procedural images are shown in Fig. 4 . The left common iliac stent was deployed carefully to prevent covering the left internal iliac artery. Sheaths were removed and closure was performed with Perclose Proglide closure devices (Abbott Vascular). Patient was discharged home in stable condition. He was given dual anti-platelet therapy with Aspirin and Plavix for 1 month.
