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The Antegrade Approach Using Transbrachial Access Improves Technical Success Rate of Endovascular Recanalization of TASC C-D Aortoiliac Occlusion in Case of Failed Femoral Access
The Antegrade Approach Using Transbrachial Access Improves Technical Success Rate of Endovascular Recanalization of TASC C-D Aortoiliac Occlusion in Case of Failed Femoral Access Antoine Millon,1,2 Nellie Della Schiava,1 Vincenzo Brizzi,1 Matthieu Arsicot,1 Tarek Boudjelit,1 Jordane Herail,1 Patrick Feugier,1 and Patrick Lermusiaux,1,2 Lyon, France
Background: Technical success rates of endovascular recanalizations for Trans-Atlantic Inter-Society Consensus (TASC) C-D chronic occlusions are highly variable and depend on the characteristics and sites of the lesions as well as on the operator experience. We hypothesized that an antegrade approach via transbrachial access could improve the technical success rate of endovascular treatment of TASC C-D occlusions in case of failed femoral access. Methods: From January 2010 to December 2012, all patients with symptomatic chronic TASC C-D aortoiliac occlusion were treated with an endovascular-first approach. Recanalization was first attempted using a femoral access. In case of failure, an antegrade approach using a transbrachial access was performed. Patient characteristics, anatomic details, procedural data, and immediate outcomes were prospectively recorded. Results: During the study period, 73 patients (99 arteries) were included. Twenty-seven (37%) patients had TASC C occlusions including 11 bilateral common iliac artery occlusions and 16 external iliac artery (EIA) occlusions involving the common femoral or the internal iliac arteries. Forty-six (63%) patients had TASC D occlusions including 10 aortoiliac occlusions, 31 unilateral occlusions of both common and EIAs, and 5 bilateral EIA occlusions. Technical success with femoral access has been obtained in 53 arteries. An antegrade approach via transbrachial access allowed technical success in the other arteries, except in 7 arteries. Overall technical success rate was 93%, and 2 complications were related to the brachial accesses including 1 thrombosis and 1 pseudoaneurysm both requiring a reintervention. Conclusions: Brachial access for TASC C-D aortoiliac chronic occlusion improves the technical success rate without the need for reentry devices.
Conflict of Interest: None. 1 Department of Vascular and Endovascular Surgery, University Hospital of Lyon, Lyon, France. 2 University Claude Bernard Lyon 1, Lyon, France. Correspondence to: Antoine Millon, MD, PhD, Department of Vascular and Endovascular Surgery, E Herriot Hospital, 5 Place d’Arsonval, Lyon Cedex 03, Lyon 69437, France; E-mail: antoinemillon@ hotmail.com
Ann Vasc Surg 2015; 29: 1346–1352 http://dx.doi.org/10.1016/j.avsg.2015.04.073 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: December 29, 2014; manuscript accepted: April 26, 2015; published online: June 26, 2015.
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INTRODUCTION Patients with symptomatic occlusive aortoiliac disease require revascularization for limb salvage or more frequently for claudication. Revascularizations can be performed either by open surgery or by endovascular techniques. Currently, indications are guided by the Trans-Atlantic Inter-Society Consensus (TASC) II statement, which has been published in 2007.1 According to the TASC II guidelines, the choice of the approach (surgery or endovascular) depends on the general condition
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of the patient, the likelihood of initial and clinical success, and the long-term patency. TASC C and D lesions represent unilateral or bilateral long iliac stenoses or occlusions, for which open revascularization is recommended. But since 2007, several studies have shown high technical success rates for endovascular repairs in TASC C-D lesions.2e4 Although technical success is high for endovascular revascularization in TASC C and D stenoses, recanalization of TASC C-D chronic occlusions is often more challenging. Failures are mostly related to the inability to cross the occlusion with a guidewire or to reenter the true lumen after accidental or intentional subintimal dissection. Technical success rates are highly variable and depend on characteristics and sites of the lesions as well as on the operators’ experience. Some authors have reported the use of reentry devices to overcome this issue.5e7 However, their use in the setting of the aorta is restricted because of concerns about an arterial rupture resulting from a reentry puncture or ballooning. Antegrade approach of these aortoiliac occlusions via a transbrachial access seems to facilitate the distal reentry into the true lumen and could be safer.8 The aim of this study was to assess the benefit of the antegrade approach via a transbrachial access in case of failed femoral access during the TASC C-D occlusions’ endovascular treatment.
MATERIAL AND METHODS Patients From January 2010 to December 2012, all patients with symptomatic chronic TASC C-D aortoiliac disease were treated by an endovascular-first approach. Patient demographics, risk factors, and indications for the procedure were prospectively recorded in a database. Symptoms of lower extremity ischemia were classified into intermittent claudication and chronic critical limb ischemia. All patients underwent preoperative peripheral arterial evaluation with color duplex ultrasonography, measurement of ankle-brachial index, and computed tomography angiography to determine the TASC classification and to plan the procedure (approach, balloon, and stent diameters). Procedural details and outcome data such as periprocedural complications, morbidity, mortality, and need for secondary procedures were also recorded. Data of patients with TASC C-D chronic total occlusions were extracted from this database for this study. The study was approved by our local ethics committee. Patients with associated abdominal aortic aneurysm,
Transbrachial access for aortoiliac occlusion 1347
acute embolism, and juxtarenal aortic occlusions were excluded, but patients with distal aortic occlusions were included in the protocol. Hybrid procedures including femoral endarterectomy were also excluded. Endovascular Technique All the procedures were performed in the operative room with a mobile C-arm. The left arm was systematically prepared for a possible brachial access. Recanalization was first attempted using percutaneous femoral access under ultrasound guidance. Access was performed at the common femoral artery (CFA) level or 2e3 cm below the origin of the superficial femoral artery depending on lesions at the CFA level. Recanalization was first attempted using an ipsilateral retrograde femoral approach except for external iliac artery (EIA) occlusions that involve the CFA for which an antegrade approach using the contralateral femoral access was first attempted. In case of failure, an antegrade approach via left transbrachial access was carried out. Ultrasoundguided puncture of the left brachial artery at the antecubital fossa was followed by placement of a 5F sheath (90e110 cm length; Cook Medical) in the abdominal aorta. A hydrophilic soft-tip 0.035-in glide wire (Advantage; Terumo Medical Corporation) was used in combination with a 125 cm length angled catheter (Slip-Cath BeaconTip catheter, 5F, 125 cm, tip configuration vtk; Cook Medical). Once the lesion crossed, the wire was retrieved by a snare from the ipsilateral side or by direct catheterization of the femoral introducer (‘‘through-and-through wire’’). In case of reentry failure in the external iliac or femoral artery true lumen, the wire was retrieved in the subintimal space (CART technique).9 After this, the procedure was continued using an ipsilateral femoral approach in the usual manner. This technique avoided manipulations of larger sheath (7F or 8F) in the brachial artery. Predilation was systematically performed before stenting using a 3-mm diameter balloon to reduce the risk of embolism and to ease the ascension of a long sheath across the occlusion. For aortic occlusions, 14e16 mm diameter balloonexpandable stents were used (Genesis, Cordis, and Advanta V12; Maquet). Stents used for common iliac occlusions were 8e10 mm diameter balloonexpandable stents (Genesis, Cordis at the beginning of our experience and covered stent Advanta V12, Maquet from January 2011 based on COBEST Trial results10). Stents used in external iliac and common femoral occlusions were 6e8 mm
1348 Millon et al.
diameter self-expanding nitinol stents (Lifestent; Bard) and were remodeled using a balloon 1-mm diameter less than the stent. Completion angiograms were performed in all cases. In case of unusual pain or sudden drop in blood pressure, an angiogram was performed and a covered stent (Fluency; Bard) was placed if some extravasation was identified (Supplemental data). No antiplatelet loading-dose was given preoperatively. Intravenous anticoagulation (heparin, 50UI/kg) and antiplatelet (aspirin, 100mg) were given at the beginning of the procedure. Double antiplatelets regimen (aspirin + clopridogrel) were prescribed for 3 months. Closure device was used for the femoral puncture site. Manual compression was performed for the brachial puncture site. End Points The primary end point was the technical success rate. Technical success was defined as <30% residual stenosis on the completion angiography. Subintimal guidewire passage was determined by the surgeon based on the following criteria: resistance and visual aspect of the guidewire when crossing the occlusion and difficulty to reentry in the true lumen. Secondary end points included in-hospital major complications. Major complications included death, myocardial infarction, stroke, contrastinduced nephropathy, complications at the access site (occlusion and pseudoaneurysm), acute thrombotic occlusion of a treated artery, and distal embolization. Statistical Methods Data are presented as mean, standard deviation for quantitative variables and as number, corresponding percentage for qualitative variables.
RESULTS Patients Between January 2010 and December 2012, 73 patients (99 iliac arteries) with TASC C and D chronic aortoiliac occlusions were treated using an endovascular approach. Indications for revascularization were severe claudication (Rutherford I, grade 3) in 59 (81%) patients, critical limb ischemia in 14 (19%) patients with rest pain (Rutherford II, 6 patients), and gangrene (Rutherford IIIeIV, 8 patients). Atherosclerotic risk factors and clinical symptoms are summarized in Table I.
Annals of Vascular Surgery
Table I. Patients risk factors and clinical symptoms Variable
n (%)
Age, years, mean ± SD Gender, male Hypertension Hyperlipidemia Diabetes mellitus Current smoker Severe claudication Rest pain Ulceration/gangrene Ankle-brachial index, mean ± SD
61.4 ± 11.1 60 (82) 41 (56) 33 (45) 15 (21) 40 (55) 59 (81) 6 (8) 8 (11) 0.59 ± 0.2
SD, standard deviation.
Lesions Twenty-seven (37%) patients had TASC C occlusions including 11 bilateral common iliac artery (CIA) occlusions and 16 EIA occlusions that involve the origins of the internal iliac artery (6 patients) or the CFA (10 patients). Forty-six (63%) patients had TASC D occlusions including10 infrarenal aortoiliac occlusions, 31 unilateral occlusion of both CIA and EIA, and 5 bilateral EIA occlusions. In addition to the 10 patients who had an occlusion of the EIA associated with an occlusion of the CFA, 10 patients had severe lesions of the CFA with 1 occlusion and 9 significant stenoses. Technical Success Technical success has been obtained in 92 (93%) iliac arteries. Occlusions were successfully crossed intraluminally in 23 arteries (25%) and subintimally in 69 arteries (75%). Occlusions were successfully crossed via femoral access in 53 arteries: using a retrograde approach via ipsilateral femoral access for 38 arteries and using an antegrade approach via contralateral femoral access for 15 arteries. Failure of femoral access was observed in 46 arteries. An antegrade approach via transbrachial access was then performed allowing successful recanalization in 39 arteries (42%). The antegrade approach via brachial access increased the technical success rate from 53% to 93% (Table II). Technical failure of the antegrade approach among these patients with a failed femoral approach was observed in 5 (7%) patients, 7 (7%) iliac arteries. Three of them had bilateral EIA occlusions, 1 had both CIA and EIA occluded and 1 had unilateral EIA occlusion that involved the CFA. Among these 5 patients, brachial accesses could not be
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Transbrachial access for aortoiliac occlusion 1349
Table II. Use of transbrachial access and technical success Lesions
TASC C Bilateral CIA occlusion Unilateral EIA occlusion that involves the origins of IIA Unilateral EIA occlusion that involves the CFA TASC D Infrarenal aortoiliac occlusion Unilateral occlusions of both CIA and EIA Bilateral occlusions of EIA
performed because of occlusion or stenosis of the left subclavian artery in 2 patients who had bilateral EIA occlusions (4 arteries). An antegrade brachial approach was unsuccessful in 3 arteries: - Unilateral EIA occlusion that involves the CFA because of inability to achieve reentry into the true lumen. - Both CIA and EIA occlusion because of impossibility to cross the lesion. - EIA occlusion in a patient with bilateral occlusion because of inability to achieve reentry into the true lumen on 1 side. Among these 5 technical failures, 4 patients underwent a delayed open revascularization: aortobifemoral bypass in 2 patients, direct iliofemoral bypass in 1 patient, and crossover iliofemoral bypass in 1 patient. The patient who had bilateral EIA occlusion with a failed recanalization did not undergo any open procedure due to his poor clinical condition. Four patients (5%) presented with a rupture of the EIA. Two of them received a covered stent and 2 ruptures were unnoticed on the completion angiogram, these 2 patients died in the postoperative period. No immediate open conversion was observed. Operative details are described in Table III. Postoperative Course In-hospital mortality. Thirty-day procedural mortality rate was 2.7%. Two deaths occurred in the postoperative course. Both were related to a rupture of the EIA that went unnoticed on the completion angiogram. One patient had delayed external iliac rupture few hr after the procedure and required urgent covered stent implantation. Indication for this patient was an occlusion of both left CIA and EIA occlusion and right EIA occlusion. This patient was at high surgical risk and died from a multiorgan
Arteries, n (patients)
Brachial approach (arteries)
Technical success (%)
22 (11) 6 (6) 10 (10)
5 3 1
22 (100) 6 (100) 9 (90)
20 (10) 31 (31) 10 (5)
16 13 1
20 (100) 30 (97) 4 (40)
failure related to a hemorrhagic shock the day after the procedure. The second patient had both right CIA and EIA occlusion and suddenly died the night after the procedure. Secondary iliac rupture could not be eliminated. There was no other in-hospital death. In-hospital morbidity. Thirty-day procedural morbidity rate was 6.8%. Five patients required a secondary procedure. Reasons for these procedures were 1 distal embolization, 2 femoral occlusions at the level of the bifurcation, 1 brachial artery occlusion, and 1 brachial artery pseudoaneurysm. Brachial siteerelated complications rate was 6.6%. Major complications and their management are summarized in Table IV. No major medical complications such as myocardial infarction, stroke, or acute renal failure were observed. Mean length of stay was 4 days (±25).
DISCUSSION Our results suggest that an antegrade approach using a transbrachial access improves the technical success rate TASC C-D occlusions’ endovascular treatment. Furthermore, brachial access is associated with a low morbidity rate. TASC C-D aortoiliac occlusions are very complex lesions (bilateral and/or extensive). Endovascular approaches for such lesions remain challenging. Procedures are long and require preoperative planning and many endovascular devices (wire guides, catheters, and introducers). The procedure depends on the lesions (nature and extension), the ability to cross with a guidewire, and reenter in the true lumen in case of subintimal route. Moreover, to our knowledge, there is no anatomic factor able to predict the intraluminal or subintimal route during recanalization and therefore the better approach (antegrade or retrograde). In our experience, all efforts are made to stay into the true lumen and avoid reentry issues. Despite these efforts, a subintimal
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Table III. Procedural characteristics Anesthesia (patients), n (%) Local 56 (77) Spinal anesthesia 9 (12) General 8 (11) Recanalization (arteries), n (%) Intraluminal 23 (25) Subintimal 69 (75) Retrograde approach using ipsilateral 38 (42) transfemoral access Antegrade approach using contralateral 15 (16) transfemoral access Antegrade approach using transbrachial 39 (42) access Operative time, min, mean ± SD 160 (±83) Radiation exposure, dose area product, 2.72 (±2.52) mGy.m2, mean ± SD Contrast used, mL, mean ± SD 99 (±47) SD, standard deviation.
dissection was performed in 75% of cases, and in more than a half of these cases, a brachial approach was required. The comparative analysis of our results with those reported in the literature is difficult. We chose to focus our study on TASC C-D aortoiliac occlusions to be consistent with TASC II classification. Previous studies report results of endovascular management of TASC C-D aortoiliac lesions with a technical success rates from 85% to 100%.2e4 This high technical success rate should be interpreted with caution. These studies mixed stenosis and occlusions. Several studies report results of iliac occlusions’ endovascular treatment but with a small number of patients. In most of these studies, TASC B occlusions were included, whereas aortic occlusions were not. Technical success rates vary between 84% and 96%.11e15 Frequent use of reentry devices have been described (up to 45% of the cases) while brachial access was performed in only 3e10% cases (when reported). Few studies report the endovascular results of infrarenal aortic occlusions’ endovascular management.16e18 Technical success rates range from 73% to 93% with extensive use of brachial approach. Our study reports our results of TASC C-D aortoiliac occlusions as described in the TASC II classification (including bilateral iliac occlusions and aortic occlusions). We report a technical success rate of 92% without using reentry devices. This good result compared with the literature is explained by the extensive use of a brachial access. Retrograde approach often requires extending the dissection to the aorta. At this level to reenter, the true lumen
Annals of Vascular Surgery
may be very challenging with the risk of bleeding. The antegrade approach using contralateral femoral access is the appropriate approach for EIA occlusion extending to the CFA. However, for CIA occlusion, this approach does not allow enough stability and enough pushability, especially for calcified occlusions. The antegrade approach using transbrachial access with long sheaths and dedicated catheters appears to be the route of choice for aortic occlusions and long iliac occlusions. This approach offers a better pushability and allows an access to both iliac arteries. The antegrade nature may ease the distal reentry in the true lumen. Moreover, reentry issues at the level of the EIA or the CFA can be managed more easily and more safely than at the aortic level. In our study, we report the use of transbrachial access for 9 of 10 aortic occlusions which is in agreement with literature.16e18 In cases of long iliac occlusions involving the origin of the CIA, we report the use of transbrachial access in 42%. Surprisingly, transbrachial access was required in only 27% of cases of bilateral CIA occlusion probably because of better pushability of the catheters positioned in the distal segment of the CIA. Complications related to brachial accesses included a pseudoaneurysm and an occlusion in 2 patients. These data confirm that brachial accesses can be used safely in most patients. Alvarez-Tostado et al.,19 reported results of 289 brachial accesses for endovascular procedures with similar results. They observed a brachial sitee related complication rate of 6.5% comparable with our results. Our results are in line with Dosluoglu’s8 experience who performed preferentially an antegrade transbrachial approach for aortic and calcified CIA occlusions. They rarely need reentry devices and confirm that access site complications are rare. Pulli et al.,20 also reported excellent results for endovascular iliac recanalization without using reentry devices. They performed a brachial access in 30% of cases. Bilateral EIA occlusions appear to be the most challenging cases with a high rate of technical failure (60% in our series). Anatomic analyses of these cases revealed heavily calcified arteries extending to the femoral bifurcation. In such cases hybrid procedures with femoral thromboendarterectomy may help to achieve reentry. Dosluoglu et al. confirmed excellent results reported by the Darmouth group of such complex hybrid procedures.21,22 Reentry devices or blunt microdissection catheters would be helpful in such cases. Moreover, femoral bifurcation endovascular management preliminary results are promising.23,24
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Transbrachial access for aortoiliac occlusion 1351
Table IV. Perioperative major adverse events Death Cause
Lesions
Access
Delay
EIA rupture
Unilateral occlusions of both CIA and EIA + contralateral EIA occlusion Unilateral occlusions of both CIA and EIA
Antegrade approach
D0
Retrograde approach
D1
Secondary interventions Cause
Lesions
Access
Delay
Reintervention
Distal embolization Common femoral occlusion
Unilateral occlusions of both CIA and EIA Unilateral occlusions of both CIA and EIA Unilateral EIA occlusion that involves the CFA Infrarenal aortoiliac occlusion
Retrograde approach Retrograde approach Retrograde approach
D1 D2 D3
Open embolectomy Open embolectomy Iliofemoral bypass
Antegrade approach
D3
Open repair
Bilateral CIA Occlusion
Antegrade approach
D2
Open repair
Brachial artery occlusion Brachial artery pseudoaneurysm
We report a 30-day mortality rate of 2.7% which is consistent with the literature.11e17 Both deaths were related to an EIA rupture undiagnosed during the procedure. Intraoperative EIA rupture is a welldescribed complication in endovascular procedure for aortoiliac occlusive disease.25 The rate of EIA rupture is between 2% and 6% in clinical studies reporting results of complex aortoiliac occlusion’s endovascular management.13e15 Most of the time, a rupture is diagnosed during the procedure while performing the angiogram, and hemostasis can easily be performed with the placement of a covered stent. This complication should be recognized during the procedure. Delayed diagnosis in such case can lead to shock and death. We observed 4 cases of EIA rupture in our series (4%). Two were detected during the procedure and immediately treated with a covered stent. The 2 others were not identified during the procedure and led to death. All these ruptures occurred at the beginning of our experience and concerned EIA occlusions. Retrospective anatomic analysis revealed small and heavily calcified EIA. More liberal or systematic use of covered stent in EIA occlusion should prevent this potentially fatal complication. Recent meta-analysis comparing outcomes of endovascular and open bypass treatment for TASC C-D aortoiliac occlusive disease reports more complications and greater 30-day mortality with open bypass.26 Endovascular treatment could be proposed to patients at high surgical risk. Regarding the durability, open bypass appears to be significantly superior to endovascular treatment. Randomized controlled trials comparing
open revascularization and endovascular treatment are required to better define the best treatment for these patients. Our study had some limitations. Experience in complex endovascular procedure management was different among surgeons. This may have impacted the technical success. However, preoperative planning was systematically performed during meeting with the whole team. Nature of lesions (unilateral or bilateral, calcification, or thrombotic occlusion) was also variable. We have no results regarding anatomic predictive factors for femoral access failure. In conclusion, we demonstrated that antegrade approach using transbrachial access for TASC C-D aortoiliac chronic occlusions’ endovascular management in case of failed femoral access allows obtaining an excellent technical success rate without the need for reentry devices. However, these procedures remain complex, and the risk of EIA rupture should be taken into account.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.avsg.2015. 04.073. REFERENCES 1. Norgren L, Hiatt WR, Dormandy JA, et al., TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg 2007;33:S1e75.
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2. Jongkind V, Akkersdijk GJ, Yeung KK, et al. A systematic review of endovascular treatment of extensive aortoiliac occlusive disease. J Vasc Surg 2010;52:1376e83. 3. Ye W, Liu CW, Ricco JB, et al. Early and late outcomes of percutaneous treatment of TransAtlantic Inter-Society Consensus class C and D aorto-iliac lesions. J Vasc Surg 2011;53:1728e37. 4. Sixt S, Krankenberg H, M€ ohrle C, et al. Endovascular treatment for extensive aortoiliac artery reconstruction: a singlecenter experience based on 1712 interventions. J Endovasc Ther 2013;20:64e73. 5. Rezq A, Aprile A, Sangiorgi G. Pioneer re-entry device for iliac chronic total occlusion: truly a paradigm shift. Catheter Cardiovasc Interv 2013;82:495e9. 6. Abisi S, Kapur R, Braithwaite B, et al. The feasibility of reentry device in recanalization of TASC C and D iliac occlusions. Vasc Endovascular Surg 2011;45:352e5. 7. Tapping CR, Uri IF, Dixon S, et al. Successful recanalization of a longstanding right common iliac artery occlusion with a radiofrequency guidewire. Cardiovasc Intervent Radiol 2012;35:1221e5. 8. Dosluoglu HH. Commentary: endovascular therapy should be the first line of treatment in patients with severe (TASC II C or D) aortoiliac occlusive disease. J Endovasc Ther 2013;20:74e9. 9. Rogers RK, Tsai T, Casserly IP. Novel application of the ‘‘CART’’ technique for endovascular treatment of external iliac artery occlusions. Catheter Cardiovasc Interv 2010;75: 673e8. 10. Mwipatayi BP, Thomas S, Wong J, et al., Covered Versus Balloon Expandable Stent Trial (COBEST) Co-investigators. A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease. J Vasc Surg 2011;54:1561e70. 11. Leville CD, Kashyap VS, Clair DG, et al. Endovascular management of iliac artery occlusions: extending treatment to TransAtlantic Inter-Society Consensus class C and D patients. J Vasc Surg 2006;43:32e9. 12. Ozkan U, Oguzkurt L, Tercan F. Technique, complication, and long-term outcome for endovascular treatment of iliac artery occlusion. Cardiovasc Intervent Radiol 2010;33: 18e24. 13. Chen BL, Holt HR, Day JD, et al. Subintimal angioplasty of chronic total occlusion in iliac arteries: a safe and durable option. J Vasc Surg 2011;53:367e73.
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14. Dattilo PB, Tsai TT, Garcia JA, et al. Clinical outcomes with contemporary endovascular therapy of iliac artery occlusive disease. Catheter Cardiovasc Interv 2012;80:644e54. 15. Sachwani GR, Hans SS, Khoury MD, et al. Results of iliac stenting and aortofemoral grafting for iliac artery occlusions. J Vasc Surg 2013;57:1030e7. 16. Krankenberg H, Schl€ uter M, Schwencke C, et al. Endovascular reconstruction of the aortic bifurcation in patients with Leriche syndrome. Clin Res Cardiol 2009;98: 657e64. 17. Kim TH, Ko YG, Kim U, et al. Outcomes of endovascular treatment of chronic total occlusion of the infrarenal aorta. J Vasc Surg 2011;53:1542e9. 18. Moise MA, Alvarez-Tostado JA, Clair DG, et al. Endovascular management of chronic infrarenal aortic occlusion. J Endovasc Ther 2009;16:84e92. 19. Alvarez-Tostado JA, Moise MA, Bena JF, et al. The brachial artery: a critical access for endovascular procedures. J Vasc Surg 2009;49:378e85. 20. Pulli R, Dorigo W, Fargion A, et al. Early and long-term comparison of endovascular treatment of iliac artery occlusions and stenosis. J Vasc Surg 2011;53:92e8. 21. Dosluoglu HH, Lall P, Cherr GS, et al. Role of simple and complex hybrid revascularization procedures for symptomatic lower extremity occlusive disease. J Vasc Surg 2010; 51:1425e1435.e1. 22. Chang RW, Goodney PP, Baek JH, et al. Long-term results of combined common femoral endarterectomy and iliac stenting/stent grafting for occlusive disease. J Vasc Surg 2008;48: 362e7. 23. Bonvini RF, Rastan A, Sixt S, et al. Endovascular treatment of common femoral artery disease: medium-term outcomes of 360 consecutive procedures. J Am Coll Cardiol 2011;58: 792e8. 24. Thiney PO, Millon A, Boudjelit T, et al. Angioplasty of the common femoral artery and its bifurcation. Ann Vasc Surg 2015;29:960e7. 25. Allaire E, Melliere D, Poussier B, et al. Iliac artery rupture during balloon dilatation: what treatment? Ann Vasc Surg 2003;17:306e14. 26. Indes JE, Pfaff MJ, Farrokhyar F, et al. Clinical outcomes of 5358 patients undergoing direct open bypass or endovascular treatment for aortoiliac occlusive disease: a systematic review and meta-analysis. J Endovasc Ther 2013;20: 443e55.
Background: Technical success rates of endovascular recanalizations for Trans-Atlantic Inter-Society Consensus (TASC) C-D chronic occlusions are highly variable and depend on the characteristics and sites of the lesions as well as on the operator experience. We hypothesized that an antegrade approach via transbrachial access could improve the technical success rate of endovascular treatment of TASC C-D occlusions in case of failed femoral access. Methods: From January 2010 to December 2012, all patients with symptomatic chronic TASC C-D aortoiliac occlusion were treated with an endovascular-first approach. Recanalization was first attempted using a femoral access. In case of failure, an antegrade approach using a transbrachial access was performed. Patient characteristics, anatomic details, procedural data, and immediate outcomes were prospectively recorded. Results: During the study period, 73 patients (99 arteries) were included. Twenty-seven (37%) patients had TASC C occlusions including 11 bilateral common iliac artery occlusions and 16 external iliac artery (EIA) occlusions involving the common femoral or the internal iliac arteries. Forty-six (63%) patients had TASC D occlusions including 10 aortoiliac occlusions, 31 unilateral occlusions of both common and EIAs, and 5 bilateral EIA occlusions. Technical success with femoral access has been obtained in 53 arteries. An antegrade approach via transbrachial access allowed technical success in the other arteries, except in 7 arteries. Overall technical success rate was 93%, and 2 complications were related to the brachial accesses including 1 thrombosis and 1 pseudoaneurysm both requiring a reintervention. Conclusions: Brachial access for TASC C-D aortoiliac chronic occlusion improves the technical success rate without the need for reentry devices.
Conflict of Interest: None. 1 Department of Vascular and Endovascular Surgery, University Hospital of Lyon, Lyon, France. 2 University Claude Bernard Lyon 1, Lyon, France. Correspondence to: Antoine Millon, MD, PhD, Department of Vascular and Endovascular Surgery, E Herriot Hospital, 5 Place d’Arsonval, Lyon Cedex 03, Lyon 69437, France; E-mail: antoinemillon@ hotmail.com
Ann Vasc Surg 2015; 29: 1346–1352 http://dx.doi.org/10.1016/j.avsg.2015.04.073 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: December 29, 2014; manuscript accepted: April 26, 2015; published online: June 26, 2015.
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INTRODUCTION Patients with symptomatic occlusive aortoiliac disease require revascularization for limb salvage or more frequently for claudication. Revascularizations can be performed either by open surgery or by endovascular techniques. Currently, indications are guided by the Trans-Atlantic Inter-Society Consensus (TASC) II statement, which has been published in 2007.1 According to the TASC II guidelines, the choice of the approach (surgery or endovascular) depends on the general condition
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of the patient, the likelihood of initial and clinical success, and the long-term patency. TASC C and D lesions represent unilateral or bilateral long iliac stenoses or occlusions, for which open revascularization is recommended. But since 2007, several studies have shown high technical success rates for endovascular repairs in TASC C-D lesions.2e4 Although technical success is high for endovascular revascularization in TASC C and D stenoses, recanalization of TASC C-D chronic occlusions is often more challenging. Failures are mostly related to the inability to cross the occlusion with a guidewire or to reenter the true lumen after accidental or intentional subintimal dissection. Technical success rates are highly variable and depend on characteristics and sites of the lesions as well as on the operators’ experience. Some authors have reported the use of reentry devices to overcome this issue.5e7 However, their use in the setting of the aorta is restricted because of concerns about an arterial rupture resulting from a reentry puncture or ballooning. Antegrade approach of these aortoiliac occlusions via a transbrachial access seems to facilitate the distal reentry into the true lumen and could be safer.8 The aim of this study was to assess the benefit of the antegrade approach via a transbrachial access in case of failed femoral access during the TASC C-D occlusions’ endovascular treatment.
MATERIAL AND METHODS Patients From January 2010 to December 2012, all patients with symptomatic chronic TASC C-D aortoiliac disease were treated by an endovascular-first approach. Patient demographics, risk factors, and indications for the procedure were prospectively recorded in a database. Symptoms of lower extremity ischemia were classified into intermittent claudication and chronic critical limb ischemia. All patients underwent preoperative peripheral arterial evaluation with color duplex ultrasonography, measurement of ankle-brachial index, and computed tomography angiography to determine the TASC classification and to plan the procedure (approach, balloon, and stent diameters). Procedural details and outcome data such as periprocedural complications, morbidity, mortality, and need for secondary procedures were also recorded. Data of patients with TASC C-D chronic total occlusions were extracted from this database for this study. The study was approved by our local ethics committee. Patients with associated abdominal aortic aneurysm,
Transbrachial access for aortoiliac occlusion 1347
acute embolism, and juxtarenal aortic occlusions were excluded, but patients with distal aortic occlusions were included in the protocol. Hybrid procedures including femoral endarterectomy were also excluded. Endovascular Technique All the procedures were performed in the operative room with a mobile C-arm. The left arm was systematically prepared for a possible brachial access. Recanalization was first attempted using percutaneous femoral access under ultrasound guidance. Access was performed at the common femoral artery (CFA) level or 2e3 cm below the origin of the superficial femoral artery depending on lesions at the CFA level. Recanalization was first attempted using an ipsilateral retrograde femoral approach except for external iliac artery (EIA) occlusions that involve the CFA for which an antegrade approach using the contralateral femoral access was first attempted. In case of failure, an antegrade approach via left transbrachial access was carried out. Ultrasoundguided puncture of the left brachial artery at the antecubital fossa was followed by placement of a 5F sheath (90e110 cm length; Cook Medical) in the abdominal aorta. A hydrophilic soft-tip 0.035-in glide wire (Advantage; Terumo Medical Corporation) was used in combination with a 125 cm length angled catheter (Slip-Cath BeaconTip catheter, 5F, 125 cm, tip configuration vtk; Cook Medical). Once the lesion crossed, the wire was retrieved by a snare from the ipsilateral side or by direct catheterization of the femoral introducer (‘‘through-and-through wire’’). In case of reentry failure in the external iliac or femoral artery true lumen, the wire was retrieved in the subintimal space (CART technique).9 After this, the procedure was continued using an ipsilateral femoral approach in the usual manner. This technique avoided manipulations of larger sheath (7F or 8F) in the brachial artery. Predilation was systematically performed before stenting using a 3-mm diameter balloon to reduce the risk of embolism and to ease the ascension of a long sheath across the occlusion. For aortic occlusions, 14e16 mm diameter balloonexpandable stents were used (Genesis, Cordis, and Advanta V12; Maquet). Stents used for common iliac occlusions were 8e10 mm diameter balloonexpandable stents (Genesis, Cordis at the beginning of our experience and covered stent Advanta V12, Maquet from January 2011 based on COBEST Trial results10). Stents used in external iliac and common femoral occlusions were 6e8 mm
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diameter self-expanding nitinol stents (Lifestent; Bard) and were remodeled using a balloon 1-mm diameter less than the stent. Completion angiograms were performed in all cases. In case of unusual pain or sudden drop in blood pressure, an angiogram was performed and a covered stent (Fluency; Bard) was placed if some extravasation was identified (Supplemental data). No antiplatelet loading-dose was given preoperatively. Intravenous anticoagulation (heparin, 50UI/kg) and antiplatelet (aspirin, 100mg) were given at the beginning of the procedure. Double antiplatelets regimen (aspirin + clopridogrel) were prescribed for 3 months. Closure device was used for the femoral puncture site. Manual compression was performed for the brachial puncture site. End Points The primary end point was the technical success rate. Technical success was defined as <30% residual stenosis on the completion angiography. Subintimal guidewire passage was determined by the surgeon based on the following criteria: resistance and visual aspect of the guidewire when crossing the occlusion and difficulty to reentry in the true lumen. Secondary end points included in-hospital major complications. Major complications included death, myocardial infarction, stroke, contrastinduced nephropathy, complications at the access site (occlusion and pseudoaneurysm), acute thrombotic occlusion of a treated artery, and distal embolization. Statistical Methods Data are presented as mean, standard deviation for quantitative variables and as number, corresponding percentage for qualitative variables.
RESULTS Patients Between January 2010 and December 2012, 73 patients (99 iliac arteries) with TASC C and D chronic aortoiliac occlusions were treated using an endovascular approach. Indications for revascularization were severe claudication (Rutherford I, grade 3) in 59 (81%) patients, critical limb ischemia in 14 (19%) patients with rest pain (Rutherford II, 6 patients), and gangrene (Rutherford IIIeIV, 8 patients). Atherosclerotic risk factors and clinical symptoms are summarized in Table I.
Annals of Vascular Surgery
Table I. Patients risk factors and clinical symptoms Variable
n (%)
Age, years, mean ± SD Gender, male Hypertension Hyperlipidemia Diabetes mellitus Current smoker Severe claudication Rest pain Ulceration/gangrene Ankle-brachial index, mean ± SD
61.4 ± 11.1 60 (82) 41 (56) 33 (45) 15 (21) 40 (55) 59 (81) 6 (8) 8 (11) 0.59 ± 0.2
SD, standard deviation.
Lesions Twenty-seven (37%) patients had TASC C occlusions including 11 bilateral common iliac artery (CIA) occlusions and 16 EIA occlusions that involve the origins of the internal iliac artery (6 patients) or the CFA (10 patients). Forty-six (63%) patients had TASC D occlusions including10 infrarenal aortoiliac occlusions, 31 unilateral occlusion of both CIA and EIA, and 5 bilateral EIA occlusions. In addition to the 10 patients who had an occlusion of the EIA associated with an occlusion of the CFA, 10 patients had severe lesions of the CFA with 1 occlusion and 9 significant stenoses. Technical Success Technical success has been obtained in 92 (93%) iliac arteries. Occlusions were successfully crossed intraluminally in 23 arteries (25%) and subintimally in 69 arteries (75%). Occlusions were successfully crossed via femoral access in 53 arteries: using a retrograde approach via ipsilateral femoral access for 38 arteries and using an antegrade approach via contralateral femoral access for 15 arteries. Failure of femoral access was observed in 46 arteries. An antegrade approach via transbrachial access was then performed allowing successful recanalization in 39 arteries (42%). The antegrade approach via brachial access increased the technical success rate from 53% to 93% (Table II). Technical failure of the antegrade approach among these patients with a failed femoral approach was observed in 5 (7%) patients, 7 (7%) iliac arteries. Three of them had bilateral EIA occlusions, 1 had both CIA and EIA occluded and 1 had unilateral EIA occlusion that involved the CFA. Among these 5 patients, brachial accesses could not be
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Transbrachial access for aortoiliac occlusion 1349
Table II. Use of transbrachial access and technical success Lesions
TASC C Bilateral CIA occlusion Unilateral EIA occlusion that involves the origins of IIA Unilateral EIA occlusion that involves the CFA TASC D Infrarenal aortoiliac occlusion Unilateral occlusions of both CIA and EIA Bilateral occlusions of EIA
performed because of occlusion or stenosis of the left subclavian artery in 2 patients who had bilateral EIA occlusions (4 arteries). An antegrade brachial approach was unsuccessful in 3 arteries: - Unilateral EIA occlusion that involves the CFA because of inability to achieve reentry into the true lumen. - Both CIA and EIA occlusion because of impossibility to cross the lesion. - EIA occlusion in a patient with bilateral occlusion because of inability to achieve reentry into the true lumen on 1 side. Among these 5 technical failures, 4 patients underwent a delayed open revascularization: aortobifemoral bypass in 2 patients, direct iliofemoral bypass in 1 patient, and crossover iliofemoral bypass in 1 patient. The patient who had bilateral EIA occlusion with a failed recanalization did not undergo any open procedure due to his poor clinical condition. Four patients (5%) presented with a rupture of the EIA. Two of them received a covered stent and 2 ruptures were unnoticed on the completion angiogram, these 2 patients died in the postoperative period. No immediate open conversion was observed. Operative details are described in Table III. Postoperative Course In-hospital mortality. Thirty-day procedural mortality rate was 2.7%. Two deaths occurred in the postoperative course. Both were related to a rupture of the EIA that went unnoticed on the completion angiogram. One patient had delayed external iliac rupture few hr after the procedure and required urgent covered stent implantation. Indication for this patient was an occlusion of both left CIA and EIA occlusion and right EIA occlusion. This patient was at high surgical risk and died from a multiorgan
Arteries, n (patients)
Brachial approach (arteries)
Technical success (%)
22 (11) 6 (6) 10 (10)
5 3 1
22 (100) 6 (100) 9 (90)
20 (10) 31 (31) 10 (5)
16 13 1
20 (100) 30 (97) 4 (40)
failure related to a hemorrhagic shock the day after the procedure. The second patient had both right CIA and EIA occlusion and suddenly died the night after the procedure. Secondary iliac rupture could not be eliminated. There was no other in-hospital death. In-hospital morbidity. Thirty-day procedural morbidity rate was 6.8%. Five patients required a secondary procedure. Reasons for these procedures were 1 distal embolization, 2 femoral occlusions at the level of the bifurcation, 1 brachial artery occlusion, and 1 brachial artery pseudoaneurysm. Brachial siteerelated complications rate was 6.6%. Major complications and their management are summarized in Table IV. No major medical complications such as myocardial infarction, stroke, or acute renal failure were observed. Mean length of stay was 4 days (±25).
DISCUSSION Our results suggest that an antegrade approach using a transbrachial access improves the technical success rate TASC C-D occlusions’ endovascular treatment. Furthermore, brachial access is associated with a low morbidity rate. TASC C-D aortoiliac occlusions are very complex lesions (bilateral and/or extensive). Endovascular approaches for such lesions remain challenging. Procedures are long and require preoperative planning and many endovascular devices (wire guides, catheters, and introducers). The procedure depends on the lesions (nature and extension), the ability to cross with a guidewire, and reenter in the true lumen in case of subintimal route. Moreover, to our knowledge, there is no anatomic factor able to predict the intraluminal or subintimal route during recanalization and therefore the better approach (antegrade or retrograde). In our experience, all efforts are made to stay into the true lumen and avoid reentry issues. Despite these efforts, a subintimal
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Table III. Procedural characteristics Anesthesia (patients), n (%) Local 56 (77) Spinal anesthesia 9 (12) General 8 (11) Recanalization (arteries), n (%) Intraluminal 23 (25) Subintimal 69 (75) Retrograde approach using ipsilateral 38 (42) transfemoral access Antegrade approach using contralateral 15 (16) transfemoral access Antegrade approach using transbrachial 39 (42) access Operative time, min, mean ± SD 160 (±83) Radiation exposure, dose area product, 2.72 (±2.52) mGy.m2, mean ± SD Contrast used, mL, mean ± SD 99 (±47) SD, standard deviation.
dissection was performed in 75% of cases, and in more than a half of these cases, a brachial approach was required. The comparative analysis of our results with those reported in the literature is difficult. We chose to focus our study on TASC C-D aortoiliac occlusions to be consistent with TASC II classification. Previous studies report results of endovascular management of TASC C-D aortoiliac lesions with a technical success rates from 85% to 100%.2e4 This high technical success rate should be interpreted with caution. These studies mixed stenosis and occlusions. Several studies report results of iliac occlusions’ endovascular treatment but with a small number of patients. In most of these studies, TASC B occlusions were included, whereas aortic occlusions were not. Technical success rates vary between 84% and 96%.11e15 Frequent use of reentry devices have been described (up to 45% of the cases) while brachial access was performed in only 3e10% cases (when reported). Few studies report the endovascular results of infrarenal aortic occlusions’ endovascular management.16e18 Technical success rates range from 73% to 93% with extensive use of brachial approach. Our study reports our results of TASC C-D aortoiliac occlusions as described in the TASC II classification (including bilateral iliac occlusions and aortic occlusions). We report a technical success rate of 92% without using reentry devices. This good result compared with the literature is explained by the extensive use of a brachial access. Retrograde approach often requires extending the dissection to the aorta. At this level to reenter, the true lumen
Annals of Vascular Surgery
may be very challenging with the risk of bleeding. The antegrade approach using contralateral femoral access is the appropriate approach for EIA occlusion extending to the CFA. However, for CIA occlusion, this approach does not allow enough stability and enough pushability, especially for calcified occlusions. The antegrade approach using transbrachial access with long sheaths and dedicated catheters appears to be the route of choice for aortic occlusions and long iliac occlusions. This approach offers a better pushability and allows an access to both iliac arteries. The antegrade nature may ease the distal reentry in the true lumen. Moreover, reentry issues at the level of the EIA or the CFA can be managed more easily and more safely than at the aortic level. In our study, we report the use of transbrachial access for 9 of 10 aortic occlusions which is in agreement with literature.16e18 In cases of long iliac occlusions involving the origin of the CIA, we report the use of transbrachial access in 42%. Surprisingly, transbrachial access was required in only 27% of cases of bilateral CIA occlusion probably because of better pushability of the catheters positioned in the distal segment of the CIA. Complications related to brachial accesses included a pseudoaneurysm and an occlusion in 2 patients. These data confirm that brachial accesses can be used safely in most patients. Alvarez-Tostado et al.,19 reported results of 289 brachial accesses for endovascular procedures with similar results. They observed a brachial sitee related complication rate of 6.5% comparable with our results. Our results are in line with Dosluoglu’s8 experience who performed preferentially an antegrade transbrachial approach for aortic and calcified CIA occlusions. They rarely need reentry devices and confirm that access site complications are rare. Pulli et al.,20 also reported excellent results for endovascular iliac recanalization without using reentry devices. They performed a brachial access in 30% of cases. Bilateral EIA occlusions appear to be the most challenging cases with a high rate of technical failure (60% in our series). Anatomic analyses of these cases revealed heavily calcified arteries extending to the femoral bifurcation. In such cases hybrid procedures with femoral thromboendarterectomy may help to achieve reentry. Dosluoglu et al. confirmed excellent results reported by the Darmouth group of such complex hybrid procedures.21,22 Reentry devices or blunt microdissection catheters would be helpful in such cases. Moreover, femoral bifurcation endovascular management preliminary results are promising.23,24
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Transbrachial access for aortoiliac occlusion 1351
Table IV. Perioperative major adverse events Death Cause
Lesions
Access
Delay
EIA rupture
Unilateral occlusions of both CIA and EIA + contralateral EIA occlusion Unilateral occlusions of both CIA and EIA
Antegrade approach
D0
Retrograde approach
D1
Secondary interventions Cause
Lesions
Access
Delay
Reintervention
Distal embolization Common femoral occlusion
Unilateral occlusions of both CIA and EIA Unilateral occlusions of both CIA and EIA Unilateral EIA occlusion that involves the CFA Infrarenal aortoiliac occlusion
Retrograde approach Retrograde approach Retrograde approach
D1 D2 D3
Open embolectomy Open embolectomy Iliofemoral bypass
Antegrade approach
D3
Open repair
Bilateral CIA Occlusion
Antegrade approach
D2
Open repair
Brachial artery occlusion Brachial artery pseudoaneurysm
We report a 30-day mortality rate of 2.7% which is consistent with the literature.11e17 Both deaths were related to an EIA rupture undiagnosed during the procedure. Intraoperative EIA rupture is a welldescribed complication in endovascular procedure for aortoiliac occlusive disease.25 The rate of EIA rupture is between 2% and 6% in clinical studies reporting results of complex aortoiliac occlusion’s endovascular management.13e15 Most of the time, a rupture is diagnosed during the procedure while performing the angiogram, and hemostasis can easily be performed with the placement of a covered stent. This complication should be recognized during the procedure. Delayed diagnosis in such case can lead to shock and death. We observed 4 cases of EIA rupture in our series (4%). Two were detected during the procedure and immediately treated with a covered stent. The 2 others were not identified during the procedure and led to death. All these ruptures occurred at the beginning of our experience and concerned EIA occlusions. Retrospective anatomic analysis revealed small and heavily calcified EIA. More liberal or systematic use of covered stent in EIA occlusion should prevent this potentially fatal complication. Recent meta-analysis comparing outcomes of endovascular and open bypass treatment for TASC C-D aortoiliac occlusive disease reports more complications and greater 30-day mortality with open bypass.26 Endovascular treatment could be proposed to patients at high surgical risk. Regarding the durability, open bypass appears to be significantly superior to endovascular treatment. Randomized controlled trials comparing
open revascularization and endovascular treatment are required to better define the best treatment for these patients. Our study had some limitations. Experience in complex endovascular procedure management was different among surgeons. This may have impacted the technical success. However, preoperative planning was systematically performed during meeting with the whole team. Nature of lesions (unilateral or bilateral, calcification, or thrombotic occlusion) was also variable. We have no results regarding anatomic predictive factors for femoral access failure. In conclusion, we demonstrated that antegrade approach using transbrachial access for TASC C-D aortoiliac chronic occlusions’ endovascular management in case of failed femoral access allows obtaining an excellent technical success rate without the need for reentry devices. However, these procedures remain complex, and the risk of EIA rupture should be taken into account.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.avsg.2015. 04.073. REFERENCES 1. Norgren L, Hiatt WR, Dormandy JA, et al., TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg 2007;33:S1e75.
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2. Jongkind V, Akkersdijk GJ, Yeung KK, et al. A systematic review of endovascular treatment of extensive aortoiliac occlusive disease. J Vasc Surg 2010;52:1376e83. 3. Ye W, Liu CW, Ricco JB, et al. Early and late outcomes of percutaneous treatment of TransAtlantic Inter-Society Consensus class C and D aorto-iliac lesions. J Vasc Surg 2011;53:1728e37. 4. Sixt S, Krankenberg H, M€ ohrle C, et al. Endovascular treatment for extensive aortoiliac artery reconstruction: a singlecenter experience based on 1712 interventions. J Endovasc Ther 2013;20:64e73. 5. Rezq A, Aprile A, Sangiorgi G. Pioneer re-entry device for iliac chronic total occlusion: truly a paradigm shift. Catheter Cardiovasc Interv 2013;82:495e9. 6. Abisi S, Kapur R, Braithwaite B, et al. The feasibility of reentry device in recanalization of TASC C and D iliac occlusions. Vasc Endovascular Surg 2011;45:352e5. 7. Tapping CR, Uri IF, Dixon S, et al. Successful recanalization of a longstanding right common iliac artery occlusion with a radiofrequency guidewire. Cardiovasc Intervent Radiol 2012;35:1221e5. 8. Dosluoglu HH. Commentary: endovascular therapy should be the first line of treatment in patients with severe (TASC II C or D) aortoiliac occlusive disease. J Endovasc Ther 2013;20:74e9. 9. Rogers RK, Tsai T, Casserly IP. Novel application of the ‘‘CART’’ technique for endovascular treatment of external iliac artery occlusions. Catheter Cardiovasc Interv 2010;75: 673e8. 10. Mwipatayi BP, Thomas S, Wong J, et al., Covered Versus Balloon Expandable Stent Trial (COBEST) Co-investigators. A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease. J Vasc Surg 2011;54:1561e70. 11. Leville CD, Kashyap VS, Clair DG, et al. Endovascular management of iliac artery occlusions: extending treatment to TransAtlantic Inter-Society Consensus class C and D patients. J Vasc Surg 2006;43:32e9. 12. Ozkan U, Oguzkurt L, Tercan F. Technique, complication, and long-term outcome for endovascular treatment of iliac artery occlusion. Cardiovasc Intervent Radiol 2010;33: 18e24. 13. Chen BL, Holt HR, Day JD, et al. Subintimal angioplasty of chronic total occlusion in iliac arteries: a safe and durable option. J Vasc Surg 2011;53:367e73.
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14. Dattilo PB, Tsai TT, Garcia JA, et al. Clinical outcomes with contemporary endovascular therapy of iliac artery occlusive disease. Catheter Cardiovasc Interv 2012;80:644e54. 15. Sachwani GR, Hans SS, Khoury MD, et al. Results of iliac stenting and aortofemoral grafting for iliac artery occlusions. J Vasc Surg 2013;57:1030e7. 16. Krankenberg H, Schl€ uter M, Schwencke C, et al. Endovascular reconstruction of the aortic bifurcation in patients with Leriche syndrome. Clin Res Cardiol 2009;98: 657e64. 17. Kim TH, Ko YG, Kim U, et al. Outcomes of endovascular treatment of chronic total occlusion of the infrarenal aorta. J Vasc Surg 2011;53:1542e9. 18. Moise MA, Alvarez-Tostado JA, Clair DG, et al. Endovascular management of chronic infrarenal aortic occlusion. J Endovasc Ther 2009;16:84e92. 19. Alvarez-Tostado JA, Moise MA, Bena JF, et al. The brachial artery: a critical access for endovascular procedures. J Vasc Surg 2009;49:378e85. 20. Pulli R, Dorigo W, Fargion A, et al. Early and long-term comparison of endovascular treatment of iliac artery occlusions and stenosis. J Vasc Surg 2011;53:92e8. 21. Dosluoglu HH, Lall P, Cherr GS, et al. Role of simple and complex hybrid revascularization procedures for symptomatic lower extremity occlusive disease. J Vasc Surg 2010; 51:1425e1435.e1. 22. Chang RW, Goodney PP, Baek JH, et al. Long-term results of combined common femoral endarterectomy and iliac stenting/stent grafting for occlusive disease. J Vasc Surg 2008;48: 362e7. 23. Bonvini RF, Rastan A, Sixt S, et al. Endovascular treatment of common femoral artery disease: medium-term outcomes of 360 consecutive procedures. J Am Coll Cardiol 2011;58: 792e8. 24. Thiney PO, Millon A, Boudjelit T, et al. Angioplasty of the common femoral artery and its bifurcation. Ann Vasc Surg 2015;29:960e7. 25. Allaire E, Melliere D, Poussier B, et al. Iliac artery rupture during balloon dilatation: what treatment? Ann Vasc Surg 2003;17:306e14. 26. Indes JE, Pfaff MJ, Farrokhyar F, et al. Clinical outcomes of 5358 patients undergoing direct open bypass or endovascular treatment for aortoiliac occlusive disease: a systematic review and meta-analysis. J Endovasc Ther 2013;20: 443e55.