atrium symposium linc 2012 dr. goverde
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Vascular Clinic ZNA
P. Goverde MD, Antwerp,Belgium
Covered
Endovascular
Reconstruction
Aortic
Bifurcation
CERAB
Better then bare stenting for
aortoiliac occlusive disease
????
Vascular Clinic ZNA
Covered
Endovascular
Reconstruction
Aortic
Bifurcation
CERAB cuff & kiss
A new technique
to reconstruct
the aortic bifurcation with
3 Atrium Advanta V12
covered stents
for occlusive disease
Vascular Clinic ZNA
How to treat ?
How to prevent ?
Vascular Clinic ZNA Kissing stent technique
Vascular Clinic ZNA
Results “kissing” stents for the treatment of complex or extensive aortoiliac occlusive disease not always satisfactory poor patency due to:
• thrombus formation
• neointimal hyperplasia
Vascular Clinic ZNA
protrusion of “kissing” stents into
the distal aortic lumen creates
a new flow divider
Vascular Clinic ZNA
protrusion of “kissing” stents into the distal aortic lumen creates a new flow divider gives rise to
• presence of immature mesenchymal tissue • intimal hyperplasia • organizing thrombus
where is this situated ?
• in the space between the opposing stents • within the lumen of the stents • at the level of the free floating intra-aortic portion of the devices
Saker M. B. , Oppat W. F. , and Kent S. A. . et al. Early failure of aortoiliac kissing stents: histopathologic correlation. J Vasc Interv Radiol 2000. 11:333–336.
Vascular Clinic ZNA protrusion of “kissing” stents into the distal aortic lumen creates a new flow divider • Saker MB, Oppat WF, Kent SA et al Early failure of aortoiliac kissing stents: histopathologic correlation. J Vasc Interv Radiol 2000. 11:333-336
• Sharafuddin MJ, Hoballah JJ, Kresowiki TF, et al. Long-term outcome following stent reconstruction of the aortic bifurcation and the role of geometric determinants. Ann Vasc Surg 2008; 22:346-357
• Greiner A, Mühlthaler H, Neuhauser et al. Does stent overlap influence patency rate of aortoiliac kissing stents? J Endovasc Ther 2005; 12: 696-703
• Hughes M, Forauer AR, Lindh M et al. Conformation of adjacent self-expanding stents : a cross sectional in vitro study. Cardiovasc Intervent Radiol 2006; 29: 255-259
Vascular Clinic ZNA
Sharafuddin MJ, Hoballah JJ,
Kresowiki TF, et al.
Long-term outcome following stent
reconstruction of the aortic
bifurcation and the role of
geometric determinants. Ann Vasc Surg 2008; 22:346-357
Vascular Clinic ZNA
Greiner A, Mühlthaler H, Neuhauser et al. Does stent overlap influence patency rate of aortoiliac kissing stents? J Endovasc Ther 2005; 12: 696-703
Vascular Clinic ZNA
Greiner A, Mühlthaler H, Neuhauser et al. Does stent overlap influence patency rate of aortoiliac kissing stents? Endovasc Ther 2005; 12: 696-703
Vascular Clinic ZNA Why using covered stents ?
• try to prevent
– adverse hemodynamic changes
– pathological changes
• promising results of stent graft use in iliac region
– Mwipatayi BP, Thomas S, Wong J et al.
A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease (COBEST). J Vasc Surg 2011,
– Sabri SS, Choudhri A, Orgera G, et al. Outcomes of covered kissing stent placement compared with bare metal stent
placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation.
J Vasc Interv Radiol. 2010 Jul;21(7):995-1003. Epub 2010 Jun 11.
– Bosiers M, Iyer V, Deloose K, et al. Flemish Experience using the Advanta V12 stent-graft for the treatment of iliac occlusive disease. J of Cardiovascular Surgery, Feb 2007, Vol 48, number 1: 7-12
Vascular Clinic ZNA Sabri SS, Choudhri A, Orgera G, et al. Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation. J Vasc Interv Radiol. 2010 Jul;21(7):995-1003. Epub 2010 Jun 11.
Vascular Clinic ZNA Sabri SS, Choudhri A, Orgera G, et al. Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation. J Vasc Interv Radiol. 2010 Jul;21(7):995-1003. Epub 2010 Jun 11.
Vascular Clinic ZNA COBEST-trial
• Prospective,randomised controled trial • Atrium Advanta V12 (81) <->bare metal stents (78) • TASC II B : +/- same results • TASC II C & D : better patency & clinical outcome
Vascular Clinic ZNA Why using ePTFE covered balloon
expandable stents?
Complete coverage of the lesion is needed
Vascular Clinic ZNA COBEST-trial
TASCII C&D
TASCII B
Vascular Clinic ZNA COBEST-trial
Vascular Clinic ZNA
Why using Atrium’s Advanta V12 covered stent
due to specific characteristics:
• low profile
• double ePTFE layer
• easy and accurate deployment
• radial force
• Dog-bone type inflation of balloon
• diameter adaptiveness (postdilation to a larger diameter is possible without damaging the
stent structure and ePTFE )
Vascular Clinic ZNA
Adaptiveness 1 stent = 4 different shapes Atrium Advanta V12 L 12x 61 mm
12mm
20mm
12mm
18mm
16mm
Vascular Clinic ZNA
Difference between “kissing” stent configuration
&
” neo” bifurcation with covered stents
Vascular Clinic ZNA CERAB - technique
Vascular Clinic ZNA
• 23 patients with aortoiliac occlusive disease
• 20 patients >6 months follow up
• TASC II C (10) and D (13) lesions.
• 12 patients received endarteriectomy of the femoral
bifurcation to ameliorate distal outflow
• Femoral access +/- brachial access
• 11 patients completely endovasculary (7 & 9 Fr)
• Technical success rate was 100%.
Vascular Clinic ZNA
CASE Example
CERAB - technique
Vascular Clinic ZNA CERAB - technique
Vascular Clinic ZNA CERAB - technique
Vascular Clinic ZNA CERAB - technique
Vascular Clinic ZNA CERAB - technique
Vascular Clinic ZNA CERAB - technique
Vascular Clinic ZNA
Vascular Clinic ZNA
Follow-up 20 ptn (> 6 months)
• 3 patients died of non-interventional causes
• relief of symptoms immediately after revascularisation
• by ultrasound (at 1,3,6 and 12 months) / CT-angiography
• re-occlusion : 3 patients (at 4,5 & 6 months)
• pt 1 : tendency to thrombocytosis,
• stop anticoagulation, total occlusion
• pt 2 : unilateral ileofemoral stenosis
• pt 3 : unilateral stenosis femoral bifurcation
• successfully thrombolysis or thrombectomy and treatment of the outflow problems.
• 14 patients showed no complications up till now.
Vascular Clinic ZNA Patient characteristics (20)
– Age : 43-75 y <57.5y>
– Sex : m : 14 / f : 6
– Follow up : 6-35 months
– Tabaco : 16 (80%)
– Cardiovascular : 14 (70%)
– Arterial Hypertension : 15 (75 %)
– Chronic renal insufficiency : 2 (10%)
– Diabetes : 8 (40%)
– Hypercholesterolaemia : 15 (75%)
– COLD : 11 (55%)
– Radiotherapy : 2 (10%)
Vascular Clinic ZNA
Patient characteristics (20)
– Aortoiliac calcifications : 13 (65%)
– Distal peripheral arterial disease : 11 (55%)
– Previous PTA : 11 (55%)
– Stents in iliac region : 6 (30%)
– Previous Vascular Surgery : 5 (20%)
– Previous CABG : 2 (10 %)
– Previous PTCA : 5 (25%)
Vascular Clinic ZNA
Follow-up : • 30 day primary patency : 100 %
• 30 day mortality : 0
• 30 day morbidity: 2
• Ecchymosis groin
• Haematoma groin (7 Fr)
Vascular Clinic ZNA
Points
of ATTENTION
Vascular Clinic ZNA Potential PROBLEM zones
Vascular Clinic ZNA
Leg occlusion
Vascular Clinic ZNA Leg occlusion
Vascular Clinic ZNA
Leg occlusion
Vascular Clinic ZNA Leg occlusion
Vascular Clinic ZNA Distal disease progression
Vascular Clinic ZNA In stent stenosis > 8 months
Advanta V12
Bare stent
Vascular Clinic ZNA Conclusions
• although small number of patients – safe and feasible technique
– completely percutaneous ( max access diameter 9 Fr).
– Hybrid procedure with i.e. endarteriectomy
• “more anatomical” reconstruction – ≈ bifurcated prosthesis, EVAR bifurcation
– better hemodynamics ?
• short and mid-term results: – encouraging
– with evidence of sustained clinical benefit
– without signs of accelerated in-stent restenosis.
• larger population & longer follow-up is needed
• “sufficient” distal outflow is recommended
Vascular Clinic ZNA
The Future ????
Vascular Clinic ZNA
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