Abstract
Atherosclerotic disease of the abdominal aorta is relatively common. However chronic stenosis of the infrarenal aorta is a fairly rare condition that has been traditionally treated with open endarterectomy and aorto-bifemoral bypass surgery. These surgeries may be associated with a significant increase in mortality and morbidity. Using 2 case examples we describe the feasibility of endovascular treatment of severely calcified infra-abdominal aortic lesion using a transradial endovascular approach that greatly reduce both vascular and access site complications.
Highlights
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Endovascular treatment of infrarenal aortic stenosis is safe and feasible.
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Transadial access minimizes vascular complication.
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Transradial endovascular repair of the infrarenal aorta is less morbid than surgical repairs available.
1
Introduction
Severe, concentric calcific stenosis of the infrarenal abdominal aorta is an uncommon and infrequent lesion and a technically challenging problem when approached endovascularly. This condition has traditionally been treated with open endarterectomy and/or aorto-bifemoral bypass surgery. While long-term patency of these operations are good (~80% in 10 years), the associated perioperative morbidity and mortality are high with up to 10% postoperative death rate [ ].
Endovascular interventions have been gaining wider acceptance as an alternative approach to surgery in the treatment of occlusive infrarenal aortic disease. Percutaneous stenting has an estimated 96% patency rate at 9 years, and is associated with minimal periprocedural adverse events. As such, the interventional approach is being proposed as first-line treatment for this condition [ ].
The atherosclerotic disease affecting the infrarenal aorta can be divided into 2 different types [ ]. The first pattern is a lesion localized to the aortic bifurcation, involving the lower part of the abdominal aorta and the common iliacs, symmetrically or not. The second pattern is relatively rare and much less investigated and includes isolated lesions of the infrarenal aorta without involvement of the aortic bifurcation.
The femoral artery is most commonly used for primary vascular access in percutaneous endovascular interventions. Vascular and bleeding complications are not infrequent with the femoral approach. The use of radial artery access in percutaneous coronary interventions has significantly reduced bleeding and access site complications, and peripheral endovascular operators have increasingly adopted this strategy such that it is now widely utilized for iliofemoral and carotid interventions [ , ]. To our knowledge, however, the use of transradial approach has not been previously reported in endovascular aortic repair. We describe our initial experience with the use of radial artery access in the percutaneous treatment of 2 patients with infrarenal aortic stenosis.
2
Case series
2.1
Patient A
A 61-year old female smoker with hypertension, dyslipidemia, and peripheral vascular disease presented with severe, progressive claudication of both buttocks and lower extremities after walking several yards. Ankle brachial index (ABI) of 0.5 was documented in both lower extremities. Abdominal aortic angiography revealed a ~90% concentric, heavily calcific stenosis just below the mesenteric artery, followed by another 60% focal lesion at the terminal aorta ( Fig. 1 ). The patient declined surgery, and subsequently underwent endovascular treatment. Vascular access was obtained at the right radial artery using a Micropunture® kit (Cook Inc., IN) and a 6-French short Glidesheath® (Terumo Inc., NJ). After injection of 3 mg verapamil into the radial artery and full anticoagulation with heparin, the target lesions at the distal aorta were crossed with a 300-cm 0.35″ stiff glidewire. Angioplasty was performed after advancing a 6.0 × 60 mm Invatec Admiral Xtreme® (Medtronic Inc., MN) balloon with a 130-cm over the wire (OTW) shaft and then a 0.014″ × 300 cm Grand Slam wire (Abbot Vascular, Santa Clara, CA) replaced the glidewire. The lesions were covered with two overlapping 8.0 × 30 mm Assurant® Cobalt (Medtronic Inc., MN) balloon-expandable stents (130-cm OTW shaft). Post-intervention angiography revealed excellent results with no residual stenosis and brisk distal flow to both iliac arteries ( Fig. 2 ).
2.2
Patient B
An 80-year old female with hypertension, dyslipidemia, coronary artery disease, and peripheral vascular disease, presenting with chronic severe claudication of both lower extremities, limiting ambulation to a few yards. ABI was <0.5 on both lower extremities. Doppler ultrasound of the abdominal aorta revealed severe stenosis of the infrarenal segment and due to exceedingly high surgical risk, the patient underwent endovascular intervention. Vascular access was obtained at the right radial artery using a Micropunture® kit (Cook Inc., IN) and a 6-French short Glidesheath® (Terumo Inc., NJ), through which 3 mg of intra-arterial verapamil was injected. Abdominal aortography revealed a focal 80% narrowing below the renal arteries, followed by moderate post-stenotic dilatation ( Fig. 3 ). After anticoagulation with heparin, the lesion was crossed with a 190-cm 0.014″ Thunder® guidewire (Medtronic Inc., MN). Intravascular ultrasonography using an Eagle Eye® IVUS catheter (Volcano Inc., CA) was advanced over the wire and showed a minimal lumen dimension of 2.8 × 4.6 mm at the stenotic segment, with a reference aortic dimension of 10 × 10 mm. The guidewire was exchanged with a 0.014″ wire-based Spider® distal protection device, the 6 mm filter of which was positioned in the right common iliac artery. After crossing the lesion, a Y connector was attached to the back of the balloon catheter, and we used it as an angiographic catheter for mapping purposes which allowed us to check for any extravasation of blood occurred in which case the balloon could have been advanced and immediately inflated until a more definitive treatment is instituted. Furthermore this technique gave us, more precision for stent placement. The angioplasty of the infrarenal aortic stenosis was performed using a 9.0 × 40 mm EverCross® (ev3 Inc., MN) balloon with a 135-cm shaft. The target lesion was then covered with an 8.0 × 40 mm EverFlex® (ev3, Inc., MN) self-expanding stent on a 120-cm shaft that was referenced based on our IVUS findings. The stent was post-dilated with the 9.0 × 40 mm balloon. Post stent IVUS measurement showed a significant improvement of the minimal lumen dimension to 6.9 × 8.1 mm and the final angiography revealed good results with <10% residual stenosis and brisk distal flow ( Fig. 4 ).
