Angioplasty of the pelvic and femoral arteries in PAOD: Results and review of the literature
Introduction
The annual incidence of symptomatic peripheral arterial obstructive disease (PAOD) is 26/10,000 in men and 12/10,000 in women according to the results of the Framingham study; this means that PAOD is at least as frequent as angina in the U.S. population [1].
The most common clinical manifestation of PAOD is intermittent claudication involving the pelvis, upper thigh and lower limb. Patients presenting with critical limb ischemia usually have multisegmental disease with involvement of the infra-inguinal arteries.
Anatomically, approximately 30% of the arterial lesions are located in the iliac arteries, 70% in the femoro-popliteal and tibial tract. Isolated lesions below the knee are present in only 15% of the cases. Approximately 30% of the symptomatic PAD patients have diffuse arterial disease, and the majority of CLI patients, most of whom are diabetic, have distal arterial disease with occlusions in the tibial arteries [2].
Considerable advances have been made over the last decade in percutaneous technology for the treatment of atherosclerotic diseases in the iliac, femoro-popliteal, and distal tibioperoneal arteries [3], [4].
The techniques that have been developed include percutaneous balloon angioplasty and stenting, atherectomy and laser therapy [3], [5], [6].
The primary goal of any treatment of patients with PAOD will be either relief of significant lifestyle-limiting symptoms or limb salvage. Surgery has long been considered the gold standard treatment when symptoms could not be controlled by risk factor modification, exercise therapy or medication. With the introduction of new interventional techniques and devices acute treatment success and durability of endovascular technology has improved during the last decade. As a result, endovascular intervention has become a first line therapy to treat PAOD in many cases and even complex arterial diseases [2].
According to the recently updated TransAtlantic Consensus Document on treatment of PAOD (TASC II), the choice between endovascular therapy and surgery depends on the lesion type in terms of complexity and length [7].
This paper presents the follow-up data of patients with PAOD treated with percutaneous transluminal recanalization either in the iliac or femoral artery and reviews the literature to date.
Section snippets
Iliac artery recanalizations
The data of 195 consecutive patients with 285 obstructions of the common and or external iliac artery were retrospectively analyzed. These patients were identified by routine registry and routine scheduled follow-up regimens. The lesions were either treated with percutaneous transluminal angioplasty (PTA) or Excimer laser assisted percutaneous transluminal angioplasty (LPTA). Overall 316 stents were implanted (Nitinol stents: 136; stainless steel stents: 180). A total of 134 men (mean age 60.9 ±
Iliac arteries
195 patients, 134 men (mean age 60.9 ± 12.5 years) and 61 women (mean age 58.8 ± 10.8 years) with intermittent claudication or chronic limb ischemia classified as Fontaine stages IIb, III or IV, were treated with PTA and stent implantation. The clinical characteristics of the patients are summarized in Table 1.
Overall 285 lesions in the pelvic arteries were detected which could be subdivided into 234 stenosis (50–74%: n = 46; 75–99%: n = 188 (Fig. 1); based on biplane angiographies and measurements in
Iliac arteries
Today the percutaneous recanalization of iliac artery obstructions is considered as method of choice in the wide majority of iliac artery lesions. Still issue for discussion remains on employed techniques for recanalization (retrograde, antegrade, primary stenting and debulking first), the outcome in female versus male patients, as well as the stent material employed (self-expanding, balloon expanding and covered stents). Besides disease progression long-term outcome also depends on outflow
Conclusion
In summary, the data on percutaneous iliac artery recanalization underline that stent-supported reconstruction of even complex lesions, classified as TASC C and D can be treated successfully with endovascular intervention (Table 3). However, further investigations should be focused on the 5- and 10 year patency rates in comparison with the surgical results. Still unresolved seems to be the discussion on primary was selective stent implantation.
Concerning the treatment of SFA lesions PTA remains
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2016, Annals of Vascular SurgeryCitation Excerpt :In the past 10 years, several factors indicating a worse prognosis have been identified in patients undergoing EVT of an iliac artery lesion including poor distal runoff, female sex, treatment of the external iliac artery (EIA), and a longer treated lesion.3 However, the effects on the outcome of some of these factors such as female sex4,5 and lesion site6,7 have been questioned by some authors. Only a few studies have compared the outcomes of EVT of stenotic lesions and chronic total occlusions (CTOs) in the iliac sector,8 mainly because lesions are usually classified according to the TASC II classification,2 which often assigns these 2 lesion types to a single class.
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