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Iliac angioplasty and stenting
Asia Pacific
Heart J 1998;7(3) Interventional
The 1998 Australasian & Asian-Pacific Cardiology Symposium Supplement
Iliac Angioplasty And Stenting David Ho,
PHD, FRACP
Department of Medicine, University of Hong Kong, Hong Kong, China Introduction The first percutaneous iliac angioplasty was performed by Dotter and Judkins in 1964.1 Over the past 3 decades, iliac angioplasty has evolved into a safe and simple procedure. The advantages of percutaneous therapy are that it: is less invasive requires only a brief hospitalisation is applicable to poor surgical candidates may be repeated if necessary. Patients with iliac artery stenosis typically complain of claudication in the hips and buttocks, with or without thigh and calve claudication. Once diagnosed, all patients with peripheral vascular disease should receive comprehensive medical management of their disease. This includes strict control of all atherosclerotic risk factors. Cessation of smoking is mandatory. Hyperlipidaemia, hypertension and diabetes should be controlled. Percutaneous transluminal angioplasty (PTA) is indicated in patients with intermittent claudications, chest pain, ulceration, gangrene or a poorly healing wound. For patients with gangrene or pregangrenous changes and impending amputation, PTA may improve the level of demarcation and amputation. The importance of a complete lower-limb angiogram to assess the level of obstruction, additional distal lesions, and the distal run-off cannot be over-emphasised. Following the PTA procedure, it is essential to verify the distal run-off to assess any clinically significant distal lesions which may be better opacified and to eliminate any distal embolisation. For patients with femoral artery disease planning to undergo femoro-popliteal bypass surgery or who have undergone bypass surgery, PTA to the iliac artery may improve the inflow. PTA may also be indicated for bypass graft stenosis or anastomotic lesions. Among patients with peripheral vascular disease (PVD), up to 78% have significant coronary artery disease.* Thus, those who have a history of exertional dyspnoea or chest discomfort suggestive of coronary artery disease should also undergo coronary angiography. This can often be performed in the same sitting as the peripheral angiography. For those with significant coronary artery disease, revascularisation of the coronary tree may take priority over revascularisation of the lower extremity vessels. Often, angiography and angioplasty of both arterial systems can be performed in one sitting by an experienced cardiologist. The decision-making may at times involve the patient’s primary physician, the peripheral interventionist and the vascular surgeon.
Techniques For iliac stenosis, particularly when the distal abdominal aorta is involved, the femoral artery is punctured in a retrograde manner as in standard coronary angiography. Depending on the size of the artery and the type of stent used, a 7 to 9Fr introducer sheath may be required. The standard short introducer sheath is often adequate for interventions on the ipsilateral side. A soft tip 0.035-inch wire will cross most of the uncomplicated stenotic lesions. There is a variety of 0.035-inch compatible balloons that one can use for performing peripheral angioplasty.
l l l l
For lesions on the ipsilateral side, one can use instruments with a working length of 60 to 70 cm. Such balloons include the SmashrM and WandarM from Schneider Ultra-thin’rM and Blue Maxm from Medi-tech, Power-FlkxrM from Cordis and Navigator IIrM from Angiomed. Sizing of the balloon can be referenced to the known outer diameter of the introducer sheath. As the vessel diameter is often several folds bigger than the reference diameter of the introducer sheath, small errors in the reference diameter can result in a big variation in the calculated vessel size. If in doubt, one should err on the conservative side, choose a balloon 1 to 2 mm smaller, and start with low inflation pressures. The manifold is connected to the side arm of the sheath to monitor the arterial pressure at the puncture site and to inject contrast media to outline the lesion. For complex lesions or total occlusions, a 6Fr diagnostic catheter of the Judkins Right or Multipurpose shape is useful in directing the soft tip guide wire to facilitate crossing the lesion. Except for short discrete lesions in large vessels which may have excellent angiographic results following simple balloon dilatation, dissection is common following balloon inflation in the femoro-iliac vessels. Several studies have shown that stenting can improve the immediate angiographic results and long-term clinical and angiographic results. Various stent designs are available for stenting in the peripheral vessels. These include the Vascular WallstentrM from Schneider, the StreckerrM stent from Medi-tech, the MemothermTM stent from Angiomed, VascucoilTM from In-stent, and the PalmazrM stent from Johnson & Johnson. For lesions in the distal external iliac, common femoral or the proximal part of the superficial femoral vessel, I prefer to perform angioplasty via a retrograde femoral puncture from the contralateral side. In this situation, one first performs angiography of the contralateral diseased limb using a Judkins Right or internal mammary graft catheter. The lesion is carefully
213
Asia Pacific
Heart J 1998;7(3) Interventional
crossed using a soft tip 0.035-inch or 0.018-inch coronary guide wire through the diagnostic catheter. Occasionally, the push-pull technique may be required to advance the diagnostic catheter over the 0.035~inch wire to cannulate selectively the external iliac, common femoral or superficial femoral artery in order to perform a more selective angiography of the vessel. Once the “roadmap” has been obtained, the diagnostic catheter can be exchanged for a short 8Fr Multipurpose guiding catheter or a long 8Fr sheath. If one is confident about the extent of the lesion and/or dissection from anatomic landmarks, one can do away with the guiding catheter. A careful push-pull technique may be required to advance the high profile peripheral angioplasty balloon or stent to the site of the lesion. Injections can be carried out through the 8Fr guiding catheter or long sheath to help localise the lesion and/or the extent of dissection following balloon dilatation. Depending on the location of the lesion, balloons and stents with a longer working length may be required when using this method. Although bilateral iliac lesions can be treated with one single femoral puncture in this manner, when one is stenting near the common iliac bifurcations, or when one wants to address stenosis in the distal abdominal aorta, it is best to puncture both femoral arteries retrogradely. It should be noted that the sheath size recommended by some of the peripheral stents refer to the inner diameter of the introducer sheath and not the inner diameter of a guiding catheter of similar French size. For example, the stent or balloon may go through a 7Fr introducer sheath but not an 8Fr guiding catheter. At times, one may need to delineate the extent of dissection by taking a “roadmap” injection through a guiding or a diagnostic catheter, exchange the catheter for the stent and deploy the stent using anatomic landmarks from the roadmap rather than real-time angiographic guidance. Following deployment of the stent and any further balloon poststent dilatation, one can exchange the stent or the balloon catheter for the diagnostic or guiding catheter to check the final angiographic results. This contralateral femoral artery puncture approach is particularly useful for dilating distal iliac, common femoral and proximal superficial femoral artery lesions, which would otherwise be impossible or may involve withdrawal of the introducer sheath on the ipsilateral side. In patients in whom the ipsilateral femoral artery is difficult to puncture or whose femoral pulse is not palpable, this method is also useful. This technique is also useful for delivering tbrombolytics to occluded iliofemoral vessels.
The 1998 Australasian & Asian-Pacific Cardiology Symposium Supplement
instructions to take one enteric-coated aspirin daily. In exceptional cases where the clinicians suspect a significant amount of thrombus, one can pretreat the lesion with continuous heparin infusion or judicious use of thrombolytics. The thromboaspiration catheter may be used in patients with a large thrombus load. When there is a large amount of residual thrombus, possible distal embolisation, or borderline distal flow, one may continue heparin infusion for several more days post-procedure. I seldom use thrombolytics for this cohort of patients. These patients tend to have diffuse atherosclerotic disease involving multiple arterial beds and a risk of intracranial haemorrhage. Results The success rate is higher for short lesions than long lesions. In one iliac PTA study involving more than 6,000 procedures, the technical success rate was 92%.3 Totally occluded lesions are associated with a lower success rate. With the availability of hydrophilic guidewires and vascular endoprosthesis, successrates for totally occluded lesions have improved over the past decade. For non-total occlusion, early clinical success rates with the availability of stents approach 99%. Long-term results for iliac PTAs are superior to those of femoral PTAs and are probably related to their larger lumen. The clinical results are better when there is good distal run-off. Whereas previous reports on iliac angioplasty suggested a slightly lower long-term patency rate compared to surgery, current results with stenting appear to be comparable or even superior to surgery. Previously reported patency rates for iliac PTA at 1, 3, and 5 years were 91%, 80% and 72% respectively.3 Recent reports using the Palmaz stent showed a patency rate of 91% and 84% at 1 and 2 years, respectively, 4 while those for the Wallstent were 95% and 88% at 1 and 2 years respectively.s-7 These results lead to the belief that long-term results from iliac PTA should be improved by systematic use of stenting. Even long and totally occluded lesions appear to achieve comparable long-term results provided primary recanalisation failure is excluded. Surgery used to be considered the treatment of choice for patients with extensive disease. However, in the typical patient with concomitant coronary and cerebrovascular disease, renal impairment or respiratory disorders, PTA is a safer alternative form of treatment. PTA is also the treatment of choice for patients with occluded grafts or secondary stenosis following bypass surgery. Even in the patient with distal femoro-popliteal or contralateral iliac obstruction, PTA to the iliac artery could complement femoro-popliteal or distal bypass, or with a crossing bypass for treating contralateral iliac occlusion. There are few randomisation studies comparing iliac angioplasty and surgery. In general, the peri-procedural mortality rate is higher in the surgical
Anticoagulation For iliac angioplasty and stenting, simple antiplatelet agents are often adequate. A bolus dose of heparin (5,000 to 10,000 IU) is adequate during the procedure. Following the procedure, the patient is discharged with
214
Asia Pacific
Heart
J 1998;7(3) Interventional
group. For aorto iliac endarterectomy, the perioperative mortality is between 1 and 16%.s The primary patency rate at 5 years ranges from 55 to 90%. For aorto-iliac bypass, the mortality rate could be as high as 18%. The patency rate at 5 years varies from 62-95%. Comparing with the old PTA techniques, there was no difference between surgery or PTA in terms of patency rate or patient survival. Even so, PTA and stenting for iliac stenosis appear to be an under-utilised procedure. Meanwhile, surgery, despite costing 5.4 times more than PTA,9 remains the first modality, if not the only modality, of treatment offered to the patient by many physicians and institutions.
The 1998 Australasian & Asian-Pacific Cardiology Symposium Supplement
success rate and a low complication rate. Nevertheless, these encouraging results can only be obtained by proper evaluation of patients, a comprehensive knowledge of anatomy and pathology, and by active consultation with our radiology and vascular surgical colleagues.
References 1.
Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction: Description of a new technic and a preliminary report of its application. Circulation 1964;30:654-70. 2. Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral vascular patients: A classification of 1,000 coronary angiograms and results of surgical management. Ann Surg 1984;199:223-33. 3. Rho11 KS, Van Breda A. Percutaneous intervention for aortoiliae disease. In: Strandness D, Van Breda A (eds). Vascular diseases: Surgical and interventional therapy. New York: Churchill Livigstone 1994:433-6. 4. Palmaz JC, Laborde JC, Rivera F J, Encarnacion CE, Lutz JD, Moss JG. Stenting of the iliac arteries with the Palmaz stent: Experience from a multicenter trial. Cardiovasc Intervent Radio1 1992;15:291-7. 5. Vorwerk D, Gunther RW. Stent placement in iliac arterial lesions: Three years of clinical experience with the Wall stent. Cardiovasc Intervent Radio1 1992;15:285-90. 6. Zollikofer CL, Antonucci F, Pfyffer M, et al. Arterial stent placement with use of the Wallstent: Midterm results of clinical experience. Radiology 1991;179:449-56. 7. Raillat C, Rousseau H, Joffre F, Roux D. Treatment of iliac artery stenoses with the Wallstent endoprosthesis. Am J Roentgen01 1990;154:613-6. 8. Brothers TE, Greenfield LJ. Long-term results of aortoiliac reconstruction. J Vast Intervent Radio1 1990; 1:49. 9. Doubilet P, Abrams HL. The cost of underutilization. Percutaneous transluminalangioplasty for peripheral vascular disease. N Engl J Med 1984;310:95-102. RF, Stronell RD, Johnston KW. Transluminal angio10. Colapinto plasty of complete iliac obstructions. Am J Roentgen01 1986;146:859-62. 11. Joseph N, Levy E, Lipman S. Angioplasty-related iliac artery rupture: Treatment by temporary balloon occlusion. Cardiovasc Intervent Radio1 1987;5:276-9. DB, McLean GK, Schwarz W. Percutaneous 12. Ring EJ, Freiman recanalisation of common iliac artery occlusions: An unacceptable complication rate? Am J Roentgen01 1982;139:587-9.
Complications The most common complications occur at the puncture site. Haematomas occur in 3% of patients. Pseudoaneurysms occur in 0.5%. Stent thrombosis occurs in 2% and is confined mainly to those with poor distal run-off. Arterial rupture may occur in up to 3% of patients.10 It can be easily treated with prolonged inflation at low pressure l1 or by deployment of a covered endoprosthesis (stent graft). Distal embolisation occurs in 3-20% of patients, especially when dealing with total occlusions.5JOJ2 These emboli are often thrombotic material but may also be atherosclerotic. In mild cases, they can be treated by heparin infusion. When there is a large thromboembolic load, thromboaspiration may be required. Clinical failure rate is about l-2%. For long and chronic total occlusions, the technical failure rate is about 5-10%.
Conclusion PTA and stenting for iliac stenosis is the first-choice therapy for iliac lesions. In my opinion, this includes total occlusive lesions, irrespective of their length or duration. With the advance of the hydrophilic wires and stents, a high percentage of these lesions can be crossed and successfully reconstructed by endovascular methods. The procedure is associated with a high clinical
Renal Angioplasty David Ho,
And Stenting
PHD, FRACP
Department of Medicine, University of Hong Kong, Hong Kong, China suspected in patients with coronary, cerebral or peripheral vascular disease, whether they are normotensive or hypertensive. The disorder should be suspected in patients with severe hypertension and rapidly progressing renal insufficiency, particularly if it develops after commencement of angiotensin-converting enzyme (ACE) inhibitor therapy. Significant RAS has been reported in up to 40% of patients with renal insufficiency undergoing coronary angiography.9
Introduction Renal artery stenosis (RAS) is a common cause of secondary hypertension.1 Severe stenosis may lead to loss of excretory function of the kidney.233Among people with atherosclerosis, a significant portion of new cases of end stage renal disease is due to ischaemic nephropathy. Several prospective studies have shown that RAS accounts for 5-22% of patients older than 50 years with advanced renal failure.d-s Renal artery stenosis should be
215
Heart J 1998;7(3) Interventional
The 1998 Australasian & Asian-Pacific Cardiology Symposium Supplement
Iliac Angioplasty And Stenting David Ho,
PHD, FRACP
Department of Medicine, University of Hong Kong, Hong Kong, China Introduction The first percutaneous iliac angioplasty was performed by Dotter and Judkins in 1964.1 Over the past 3 decades, iliac angioplasty has evolved into a safe and simple procedure. The advantages of percutaneous therapy are that it: is less invasive requires only a brief hospitalisation is applicable to poor surgical candidates may be repeated if necessary. Patients with iliac artery stenosis typically complain of claudication in the hips and buttocks, with or without thigh and calve claudication. Once diagnosed, all patients with peripheral vascular disease should receive comprehensive medical management of their disease. This includes strict control of all atherosclerotic risk factors. Cessation of smoking is mandatory. Hyperlipidaemia, hypertension and diabetes should be controlled. Percutaneous transluminal angioplasty (PTA) is indicated in patients with intermittent claudications, chest pain, ulceration, gangrene or a poorly healing wound. For patients with gangrene or pregangrenous changes and impending amputation, PTA may improve the level of demarcation and amputation. The importance of a complete lower-limb angiogram to assess the level of obstruction, additional distal lesions, and the distal run-off cannot be over-emphasised. Following the PTA procedure, it is essential to verify the distal run-off to assess any clinically significant distal lesions which may be better opacified and to eliminate any distal embolisation. For patients with femoral artery disease planning to undergo femoro-popliteal bypass surgery or who have undergone bypass surgery, PTA to the iliac artery may improve the inflow. PTA may also be indicated for bypass graft stenosis or anastomotic lesions. Among patients with peripheral vascular disease (PVD), up to 78% have significant coronary artery disease.* Thus, those who have a history of exertional dyspnoea or chest discomfort suggestive of coronary artery disease should also undergo coronary angiography. This can often be performed in the same sitting as the peripheral angiography. For those with significant coronary artery disease, revascularisation of the coronary tree may take priority over revascularisation of the lower extremity vessels. Often, angiography and angioplasty of both arterial systems can be performed in one sitting by an experienced cardiologist. The decision-making may at times involve the patient’s primary physician, the peripheral interventionist and the vascular surgeon.
Techniques For iliac stenosis, particularly when the distal abdominal aorta is involved, the femoral artery is punctured in a retrograde manner as in standard coronary angiography. Depending on the size of the artery and the type of stent used, a 7 to 9Fr introducer sheath may be required. The standard short introducer sheath is often adequate for interventions on the ipsilateral side. A soft tip 0.035-inch wire will cross most of the uncomplicated stenotic lesions. There is a variety of 0.035-inch compatible balloons that one can use for performing peripheral angioplasty.
l l l l
For lesions on the ipsilateral side, one can use instruments with a working length of 60 to 70 cm. Such balloons include the SmashrM and WandarM from Schneider Ultra-thin’rM and Blue Maxm from Medi-tech, Power-FlkxrM from Cordis and Navigator IIrM from Angiomed. Sizing of the balloon can be referenced to the known outer diameter of the introducer sheath. As the vessel diameter is often several folds bigger than the reference diameter of the introducer sheath, small errors in the reference diameter can result in a big variation in the calculated vessel size. If in doubt, one should err on the conservative side, choose a balloon 1 to 2 mm smaller, and start with low inflation pressures. The manifold is connected to the side arm of the sheath to monitor the arterial pressure at the puncture site and to inject contrast media to outline the lesion. For complex lesions or total occlusions, a 6Fr diagnostic catheter of the Judkins Right or Multipurpose shape is useful in directing the soft tip guide wire to facilitate crossing the lesion. Except for short discrete lesions in large vessels which may have excellent angiographic results following simple balloon dilatation, dissection is common following balloon inflation in the femoro-iliac vessels. Several studies have shown that stenting can improve the immediate angiographic results and long-term clinical and angiographic results. Various stent designs are available for stenting in the peripheral vessels. These include the Vascular WallstentrM from Schneider, the StreckerrM stent from Medi-tech, the MemothermTM stent from Angiomed, VascucoilTM from In-stent, and the PalmazrM stent from Johnson & Johnson. For lesions in the distal external iliac, common femoral or the proximal part of the superficial femoral vessel, I prefer to perform angioplasty via a retrograde femoral puncture from the contralateral side. In this situation, one first performs angiography of the contralateral diseased limb using a Judkins Right or internal mammary graft catheter. The lesion is carefully
213
Asia Pacific
Heart J 1998;7(3) Interventional
crossed using a soft tip 0.035-inch or 0.018-inch coronary guide wire through the diagnostic catheter. Occasionally, the push-pull technique may be required to advance the diagnostic catheter over the 0.035~inch wire to cannulate selectively the external iliac, common femoral or superficial femoral artery in order to perform a more selective angiography of the vessel. Once the “roadmap” has been obtained, the diagnostic catheter can be exchanged for a short 8Fr Multipurpose guiding catheter or a long 8Fr sheath. If one is confident about the extent of the lesion and/or dissection from anatomic landmarks, one can do away with the guiding catheter. A careful push-pull technique may be required to advance the high profile peripheral angioplasty balloon or stent to the site of the lesion. Injections can be carried out through the 8Fr guiding catheter or long sheath to help localise the lesion and/or the extent of dissection following balloon dilatation. Depending on the location of the lesion, balloons and stents with a longer working length may be required when using this method. Although bilateral iliac lesions can be treated with one single femoral puncture in this manner, when one is stenting near the common iliac bifurcations, or when one wants to address stenosis in the distal abdominal aorta, it is best to puncture both femoral arteries retrogradely. It should be noted that the sheath size recommended by some of the peripheral stents refer to the inner diameter of the introducer sheath and not the inner diameter of a guiding catheter of similar French size. For example, the stent or balloon may go through a 7Fr introducer sheath but not an 8Fr guiding catheter. At times, one may need to delineate the extent of dissection by taking a “roadmap” injection through a guiding or a diagnostic catheter, exchange the catheter for the stent and deploy the stent using anatomic landmarks from the roadmap rather than real-time angiographic guidance. Following deployment of the stent and any further balloon poststent dilatation, one can exchange the stent or the balloon catheter for the diagnostic or guiding catheter to check the final angiographic results. This contralateral femoral artery puncture approach is particularly useful for dilating distal iliac, common femoral and proximal superficial femoral artery lesions, which would otherwise be impossible or may involve withdrawal of the introducer sheath on the ipsilateral side. In patients in whom the ipsilateral femoral artery is difficult to puncture or whose femoral pulse is not palpable, this method is also useful. This technique is also useful for delivering tbrombolytics to occluded iliofemoral vessels.
The 1998 Australasian & Asian-Pacific Cardiology Symposium Supplement
instructions to take one enteric-coated aspirin daily. In exceptional cases where the clinicians suspect a significant amount of thrombus, one can pretreat the lesion with continuous heparin infusion or judicious use of thrombolytics. The thromboaspiration catheter may be used in patients with a large thrombus load. When there is a large amount of residual thrombus, possible distal embolisation, or borderline distal flow, one may continue heparin infusion for several more days post-procedure. I seldom use thrombolytics for this cohort of patients. These patients tend to have diffuse atherosclerotic disease involving multiple arterial beds and a risk of intracranial haemorrhage. Results The success rate is higher for short lesions than long lesions. In one iliac PTA study involving more than 6,000 procedures, the technical success rate was 92%.3 Totally occluded lesions are associated with a lower success rate. With the availability of hydrophilic guidewires and vascular endoprosthesis, successrates for totally occluded lesions have improved over the past decade. For non-total occlusion, early clinical success rates with the availability of stents approach 99%. Long-term results for iliac PTAs are superior to those of femoral PTAs and are probably related to their larger lumen. The clinical results are better when there is good distal run-off. Whereas previous reports on iliac angioplasty suggested a slightly lower long-term patency rate compared to surgery, current results with stenting appear to be comparable or even superior to surgery. Previously reported patency rates for iliac PTA at 1, 3, and 5 years were 91%, 80% and 72% respectively.3 Recent reports using the Palmaz stent showed a patency rate of 91% and 84% at 1 and 2 years, respectively, 4 while those for the Wallstent were 95% and 88% at 1 and 2 years respectively.s-7 These results lead to the belief that long-term results from iliac PTA should be improved by systematic use of stenting. Even long and totally occluded lesions appear to achieve comparable long-term results provided primary recanalisation failure is excluded. Surgery used to be considered the treatment of choice for patients with extensive disease. However, in the typical patient with concomitant coronary and cerebrovascular disease, renal impairment or respiratory disorders, PTA is a safer alternative form of treatment. PTA is also the treatment of choice for patients with occluded grafts or secondary stenosis following bypass surgery. Even in the patient with distal femoro-popliteal or contralateral iliac obstruction, PTA to the iliac artery could complement femoro-popliteal or distal bypass, or with a crossing bypass for treating contralateral iliac occlusion. There are few randomisation studies comparing iliac angioplasty and surgery. In general, the peri-procedural mortality rate is higher in the surgical
Anticoagulation For iliac angioplasty and stenting, simple antiplatelet agents are often adequate. A bolus dose of heparin (5,000 to 10,000 IU) is adequate during the procedure. Following the procedure, the patient is discharged with
214
Asia Pacific
Heart
J 1998;7(3) Interventional
group. For aorto iliac endarterectomy, the perioperative mortality is between 1 and 16%.s The primary patency rate at 5 years ranges from 55 to 90%. For aorto-iliac bypass, the mortality rate could be as high as 18%. The patency rate at 5 years varies from 62-95%. Comparing with the old PTA techniques, there was no difference between surgery or PTA in terms of patency rate or patient survival. Even so, PTA and stenting for iliac stenosis appear to be an under-utilised procedure. Meanwhile, surgery, despite costing 5.4 times more than PTA,9 remains the first modality, if not the only modality, of treatment offered to the patient by many physicians and institutions.
The 1998 Australasian & Asian-Pacific Cardiology Symposium Supplement
success rate and a low complication rate. Nevertheless, these encouraging results can only be obtained by proper evaluation of patients, a comprehensive knowledge of anatomy and pathology, and by active consultation with our radiology and vascular surgical colleagues.
References 1.
Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction: Description of a new technic and a preliminary report of its application. Circulation 1964;30:654-70. 2. Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral vascular patients: A classification of 1,000 coronary angiograms and results of surgical management. Ann Surg 1984;199:223-33. 3. Rho11 KS, Van Breda A. Percutaneous intervention for aortoiliae disease. In: Strandness D, Van Breda A (eds). Vascular diseases: Surgical and interventional therapy. New York: Churchill Livigstone 1994:433-6. 4. Palmaz JC, Laborde JC, Rivera F J, Encarnacion CE, Lutz JD, Moss JG. Stenting of the iliac arteries with the Palmaz stent: Experience from a multicenter trial. Cardiovasc Intervent Radio1 1992;15:291-7. 5. Vorwerk D, Gunther RW. Stent placement in iliac arterial lesions: Three years of clinical experience with the Wall stent. Cardiovasc Intervent Radio1 1992;15:285-90. 6. Zollikofer CL, Antonucci F, Pfyffer M, et al. Arterial stent placement with use of the Wallstent: Midterm results of clinical experience. Radiology 1991;179:449-56. 7. Raillat C, Rousseau H, Joffre F, Roux D. Treatment of iliac artery stenoses with the Wallstent endoprosthesis. Am J Roentgen01 1990;154:613-6. 8. Brothers TE, Greenfield LJ. Long-term results of aortoiliac reconstruction. J Vast Intervent Radio1 1990; 1:49. 9. Doubilet P, Abrams HL. The cost of underutilization. Percutaneous transluminalangioplasty for peripheral vascular disease. N Engl J Med 1984;310:95-102. RF, Stronell RD, Johnston KW. Transluminal angio10. Colapinto plasty of complete iliac obstructions. Am J Roentgen01 1986;146:859-62. 11. Joseph N, Levy E, Lipman S. Angioplasty-related iliac artery rupture: Treatment by temporary balloon occlusion. Cardiovasc Intervent Radio1 1987;5:276-9. DB, McLean GK, Schwarz W. Percutaneous 12. Ring EJ, Freiman recanalisation of common iliac artery occlusions: An unacceptable complication rate? Am J Roentgen01 1982;139:587-9.
Complications The most common complications occur at the puncture site. Haematomas occur in 3% of patients. Pseudoaneurysms occur in 0.5%. Stent thrombosis occurs in 2% and is confined mainly to those with poor distal run-off. Arterial rupture may occur in up to 3% of patients.10 It can be easily treated with prolonged inflation at low pressure l1 or by deployment of a covered endoprosthesis (stent graft). Distal embolisation occurs in 3-20% of patients, especially when dealing with total occlusions.5JOJ2 These emboli are often thrombotic material but may also be atherosclerotic. In mild cases, they can be treated by heparin infusion. When there is a large thromboembolic load, thromboaspiration may be required. Clinical failure rate is about l-2%. For long and chronic total occlusions, the technical failure rate is about 5-10%.
Conclusion PTA and stenting for iliac stenosis is the first-choice therapy for iliac lesions. In my opinion, this includes total occlusive lesions, irrespective of their length or duration. With the advance of the hydrophilic wires and stents, a high percentage of these lesions can be crossed and successfully reconstructed by endovascular methods. The procedure is associated with a high clinical
Renal Angioplasty David Ho,
And Stenting
PHD, FRACP
Department of Medicine, University of Hong Kong, Hong Kong, China suspected in patients with coronary, cerebral or peripheral vascular disease, whether they are normotensive or hypertensive. The disorder should be suspected in patients with severe hypertension and rapidly progressing renal insufficiency, particularly if it develops after commencement of angiotensin-converting enzyme (ACE) inhibitor therapy. Significant RAS has been reported in up to 40% of patients with renal insufficiency undergoing coronary angiography.9
Introduction Renal artery stenosis (RAS) is a common cause of secondary hypertension.1 Severe stenosis may lead to loss of excretory function of the kidney.233Among people with atherosclerosis, a significant portion of new cases of end stage renal disease is due to ischaemic nephropathy. Several prospective studies have shown that RAS accounts for 5-22% of patients older than 50 years with advanced renal failure.d-s Renal artery stenosis should be
215