Atrium Symposium LINC 2012 Dr. Goverde

Vascular Clinic ZNA

P. Goverde MD, Antwerp,Belgium

Covered

Endovascular

Reconstruction

Aortic

Bifurcation

CERAB

Better then bare stenting for

aortoiliac occlusive disease

????

Vascular Clinic ZNA

Covered

Endovascular

Reconstruction

Aortic

Bifurcation

CERAB cuff & kiss

A new technique

to reconstruct

the aortic bifurcation with

3 Atrium Advanta V12

covered stents

for occlusive disease

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How to treat ?

How to prevent ?

Vascular Clinic ZNA Kissing stent technique

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Results “kissing” stents for the treatment of complex or extensive aortoiliac occlusive disease not always satisfactory poor patency due to:

• thrombus formation

• neointimal hyperplasia

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protrusion of “kissing” stents into

the distal aortic lumen creates

a new flow divider

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protrusion of “kissing” stents into the distal aortic lumen creates a new flow divider gives rise to

• presence of immature mesenchymal tissue • intimal hyperplasia • organizing thrombus

where is this situated ?

• in the space between the opposing stents • within the lumen of the stents • at the level of the free floating intra-aortic portion of the devices

Saker M. B. , Oppat W. F. , and Kent S. A. . et al. Early failure of aortoiliac kissing stents: histopathologic correlation. J Vasc Interv Radiol 2000. 11:333–336.

Vascular Clinic ZNA protrusion of “kissing” stents into the distal aortic lumen creates a new flow divider • Saker MB, Oppat WF, Kent SA et al Early failure of aortoiliac kissing stents: histopathologic correlation. J Vasc Interv Radiol 2000. 11:333-336

• Sharafuddin MJ, Hoballah JJ, Kresowiki TF, et al. Long-term outcome following stent reconstruction of the aortic bifurcation and the role of geometric determinants. Ann Vasc Surg 2008; 22:346-357

• Greiner A, Mühlthaler H, Neuhauser et al. Does stent overlap influence patency rate of aortoiliac kissing stents? J Endovasc Ther 2005; 12: 696-703

• Hughes M, Forauer AR, Lindh M et al. Conformation of adjacent self-expanding stents : a cross sectional in vitro study. Cardiovasc Intervent Radiol 2006; 29: 255-259

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Sharafuddin MJ, Hoballah JJ,

Kresowiki TF, et al.

Long-term outcome following stent

reconstruction of the aortic

bifurcation and the role of

geometric determinants. Ann Vasc Surg 2008; 22:346-357

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Greiner A, Mühlthaler H, Neuhauser et al. Does stent overlap influence patency rate of aortoiliac kissing stents? J Endovasc Ther 2005; 12: 696-703

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Greiner A, Mühlthaler H, Neuhauser et al. Does stent overlap influence patency rate of aortoiliac kissing stents? Endovasc Ther 2005; 12: 696-703

Vascular Clinic ZNA Why using covered stents ?

• try to prevent

– adverse hemodynamic changes

– pathological changes

• promising results of stent graft use in iliac region

– Mwipatayi BP, Thomas S, Wong J et al.

A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease (COBEST). J Vasc Surg 2011,

– Sabri SS, Choudhri A, Orgera G, et al. Outcomes of covered kissing stent placement compared with bare metal stent

placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation.

J Vasc Interv Radiol. 2010 Jul;21(7):995-1003. Epub 2010 Jun 11.

– Bosiers M, Iyer V, Deloose K, et al. Flemish Experience using the Advanta V12 stent-graft for the treatment of iliac occlusive disease. J of Cardiovascular Surgery, Feb 2007, Vol 48, number 1: 7-12

Vascular Clinic ZNA Sabri SS, Choudhri A, Orgera G, et al. Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation. J Vasc Interv Radiol. 2010 Jul;21(7):995-1003. Epub 2010 Jun 11.

Vascular Clinic ZNA Sabri SS, Choudhri A, Orgera G, et al. Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation. J Vasc Interv Radiol. 2010 Jul;21(7):995-1003. Epub 2010 Jun 11.

Vascular Clinic ZNA COBEST-trial

• Prospective,randomised controled trial • Atrium Advanta V12 (81) <->bare metal stents (78) • TASC II B : +/- same results • TASC II C & D : better patency & clinical outcome

Vascular Clinic ZNA Why using ePTFE covered balloon

expandable stents?

Complete coverage of the lesion is needed

Vascular Clinic ZNA COBEST-trial

TASCII C&D

TASCII B

Vascular Clinic ZNA COBEST-trial

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Why using Atrium’s Advanta V12 covered stent

due to specific characteristics:

• low profile

• double ePTFE layer

• easy and accurate deployment

• radial force

• Dog-bone type inflation of balloon

• diameter adaptiveness (postdilation to a larger diameter is possible without damaging the

stent structure and ePTFE )

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Adaptiveness 1 stent = 4 different shapes Atrium Advanta V12 L 12x 61 mm

12mm

20mm

12mm

18mm

16mm

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Difference between “kissing” stent configuration

&

” neo” bifurcation with covered stents

Vascular Clinic ZNA CERAB - technique

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• 23 patients with aortoiliac occlusive disease

• 20 patients >6 months follow up

• TASC II C (10) and D (13) lesions.

• 12 patients received endarteriectomy of the femoral

bifurcation to ameliorate distal outflow

• Femoral access +/- brachial access

• 11 patients completely endovasculary (7 & 9 Fr)

• Technical success rate was 100%.

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CASE Example

CERAB - technique

Vascular Clinic ZNA CERAB - technique

Vascular Clinic ZNA CERAB - technique

Vascular Clinic ZNA CERAB - technique

Vascular Clinic ZNA CERAB - technique

Vascular Clinic ZNA CERAB - technique

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Follow-up 20 ptn (> 6 months)

• 3 patients died of non-interventional causes

• relief of symptoms immediately after revascularisation

• by ultrasound (at 1,3,6 and 12 months) / CT-angiography

• re-occlusion : 3 patients (at 4,5 & 6 months)

• pt 1 : tendency to thrombocytosis,

• stop anticoagulation, total occlusion

• pt 2 : unilateral ileofemoral stenosis

• pt 3 : unilateral stenosis femoral bifurcation

• successfully thrombolysis or thrombectomy and treatment of the outflow problems.

• 14 patients showed no complications up till now.

Vascular Clinic ZNA Patient characteristics (20)

– Age : 43-75 y <57.5y>

– Sex : m : 14 / f : 6

– Follow up : 6-35 months

– Tabaco : 16 (80%)

– Cardiovascular : 14 (70%)

– Arterial Hypertension : 15 (75 %)

– Chronic renal insufficiency : 2 (10%)

– Diabetes : 8 (40%)

– Hypercholesterolaemia : 15 (75%)

– COLD : 11 (55%)

– Radiotherapy : 2 (10%)

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Patient characteristics (20)

– Aortoiliac calcifications : 13 (65%)

– Distal peripheral arterial disease : 11 (55%)

– Previous PTA : 11 (55%)

– Stents in iliac region : 6 (30%)

– Previous Vascular Surgery : 5 (20%)

– Previous CABG : 2 (10 %)

– Previous PTCA : 5 (25%)

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Follow-up : • 30 day primary patency : 100 %

• 30 day mortality : 0

• 30 day morbidity: 2

• Ecchymosis groin

• Haematoma groin (7 Fr)

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Points

of ATTENTION

Vascular Clinic ZNA Potential PROBLEM zones

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Leg occlusion

Vascular Clinic ZNA Leg occlusion

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Leg occlusion

Vascular Clinic ZNA Leg occlusion

Vascular Clinic ZNA Distal disease progression

Vascular Clinic ZNA In stent stenosis > 8 months

Advanta V12

Bare stent

Vascular Clinic ZNA Conclusions

• although small number of patients – safe and feasible technique

– completely percutaneous ( max access diameter 9 Fr).

– Hybrid procedure with i.e. endarteriectomy

• “more anatomical” reconstruction – ≈ bifurcated prosthesis, EVAR bifurcation

– better hemodynamics ?

• short and mid-term results: – encouraging

– with evidence of sustained clinical benefit

– without signs of accelerated in-stent restenosis.

• larger population & longer follow-up is needed

• “sufficient” distal outflow is recommended

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The Future ????

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