case report balloon occlusion of the contralateral iliac...

Hindawi Publishing CorporationCase Reports in RadiologyVolume 2013 Article ID 647850 5 pageshttpdxdoiorg1011552013647850

Case ReportBalloon Occlusion of the Contralateral Iliac Artery to AssistRecanalization of the Ipsilateral Iliac Artery in Total AortoiliacOcclusion A Technical Note

Abdel Aziz A Jaffan

Division of Interventional Radiology and Image-Guided Medicine Department of Radiology Emory University School of Medicine1364 Clifton Road NE Atlanta GA 30322 USA

Correspondence should be addressed to Abdel Aziz A Jaffan aajaffangmailcom

Received 31 March 2013 Accepted 25 April 2013

Academic Editors R P Byrd and A Komemushi

Copyright copy 2013 Abdel Aziz A JaffanThis is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Endovascular recanalization of chronic total aortoiliac occlusion is technically challenging Inability to reenter the true aortic lumenfollowing retrograde iliac recanalization is one of the most common causes of failure We describe a case of a total aortoiliacocclusion where balloon occlusion of the right common iliac artery following its recanalization from a brachial approach was usedto facilitate antegrade recanalization of the occluded contralateral left common iliac artery

1 Introduction

Chronic obstruction of the aortic bifurcation involvingto a varying degree and extent both the infrarenal aorticand common iliac arteries (CIAs) can result in a triadof symptoms consisting of intermittent claudication absentor diminished peripheral pulses and impotence Classicallydescribed in males the anatomic pattern of obstruction isequally common in males and females [1] The onset ismainly between 40 and 60 years of age and the diseasecan lead to severe impairment of walking capacity restpain and wheelchair dependence [1 2] Aortobifemoralbypass has been considered the gold standard for treatingchronic aortoiliac occlusions [3] but results of endovascularrecanalization of the iliac arteries now approach those of aor-tobifemoral bypasswith reducedmorbidity andmortality andshorter hospitalization [4] The Trans-Atlantic Inter-SocietyConsensus for themanagement of PeripheralArterialDisease(TASC II) document classifies total aortoiliac occlusion astypeDwith surgery as the treatment of choice [3] Nowadaysendovascular therapy is increasingly performed in patientswith extensive aortoiliac disease including total aortoiliacocclusion [1] We describe a technique that might facilitatethe recanalization of chronic total iliac occlusion duringendovascular recanalization of a total aortoiliac occlusion

2 Case Description

The patient was a 53-year old female with multiple cardiovas-cular factors including hypertension hypercholesterolemiadiabetes mellitus coronary artery disease and history ofheavy smoking (60 pack-years quit 3 years ago) whopresented with bilateral lower extremity intermittent claudi-cation rightworse than left forcing her to stop after 3minutesof walking On physical examination her bilateral femoralpopliteal dorsalis pedis and posterior tibialis pulses were notpalpable At rest her ankle-brachial index (ABI) measured057 on the right and 058 on the left She underwent acomputed tomographic angiography (CTA) that showedcomplete occlusion of the distal abdominal aorta includingthe origin of the inferiormesenteric artery as well as the bilat-eral common iliac arteries (CIAs) with reconstitution at thelevel of the iliac bifurcations The diameter of the abdominalaorta was 12mm at the proximal aspect of the occlusion anddecreased to 9mm at the level of the bifurcation as seen onthe preplanningCTAThe right external iliac artery (EIA)was4mm and the left EIA was 5mm in diameter The occludedright CIA was 6mm and the occluded left CIA was 7mmin diameter The patient declined open surgery and optedfor endovascular therapy Left brachial arterial access wasobtained under ultrasound guidance using a micropuncture

2 Case Reports in Radiology

Figure 1 Aortogram showing total occlusion of the distal abdomi-nal aorta and bilateral common iliac arteries

Figure 2 Aortogram showing reconstitution at the level of the iliacbifurcations

access kit (CookMedical Bloomington INUSA)A 5 Frenchsheath was placed and a 5 French pigtail flush catheter (CookMedical Bloomington IN USA) was advanced into theabdominal aorta An aortogram was performed and showedcomplete occlusion of the distal infra-renal aorta andbilateral CIAs with reconstitution at the iliac bifurcations(Figures 1 and 2) Bilateral retrograde common femoral artery(CFA) access was obtained using ultrasound guidance and amicropuncture access kit Five French sheaths were insertedin the CFA bilaterally and upsized later to an 8 Frenchsheath on the left and 7 French on the right Unfractionatedheparin was injected intravenously in boluses throughout theprocedure tomaintain the activated clotting time (ACT)gt250seconds A 5 French Davis catheter (Cook Bloomington INUSA) and 003510158401015840 Glidewire (Terumo Somerset NJ USA)were used to perform antegrade subintimal recanalization ofthe right CIA from a brachial approach The Glidewire was

Figure 3 Wire retrieval from the right femoral sheath followingrecanalization of the right common iliac artery

retrieved from the right femoral sheath (Figure 3) and thenexchanged for a Rosen wire (Cook Bloomington IN USA)Subintimal recanalization of the left CIA from a femoralapproach was unsuccessful with failure to reenter the trueaortic lumen Attempts to recanalize the left CIA from abrachial approach were also unsuccessful as the wire andcatheter continued to advance into the recanalized rightCIA following the path of the least resistance To overcomethis problem the recanalized right CIA was occluded at itsorigin with a 5mm times 40mm UTD balloon catheter (BostonScientific Natick MA USA) inserted from the right femoralapproach sealing the origin of the right CIA The 5 FrenchDavis catheter was advanced from the brachial approach intothe distal abdominal aorta to the level of the occluded leftCIAWith the tip of the catheter pointed toward the occludedleftCIA the stiff back end of a 003510158401015840Glidewirewas advancedto initiate a sharp recanalization of the occluded left CIA(Figure 4) The presence of the occlusion balloon preventedthe Davis catheter from advancing into the recanalized rightCIA and forced it in the direction of the occluded left CIAThe catheter was advanced over the wire into the occludedleft CIA At this point the floppy end of the Glidewire wasadvanced through the catheter and recanalization of the leftCIA continued from a brachial approach The wire reenteredthe true lumen of the left EIA and was retrieved from the leftfemoral sheath (Figure 5) The Glidewire was exchanged fora Rosen wire advanced into the abdominal aorta From theleft femoral approach a 16mm length Intrastent DoublestrutLD balloon expandable stent (EV3 Plymouth MN USA)mounted on 10mm times 2 cm EverCross balloon catheter(EV3 Plymouth MN USA) was deployed in the proximaloccluded aortic segment and then further balloon dilatedto 12mm using a 12mm times 2 cm EverCross balloon catheter(EV3 Plymouth MN USA) (Figure 6) More distally theoccluded aortoiliac bifurcation was reconstructed using a6mm times 59mm iCAST balloon expandable covered stent

Case Reports in Radiology 3

Figure 4 Spot image at the level of the aortic bifurcation showingan inflated angioplasty balloon occluding the recanalized right CIAat its origin (A) a stiff Glidewire advanced into the occluded leftCIA from an antegrade brachial approach (B) and a 5 Frenchangiographic catheter in the retrograde subintimal tract of the leftCIA advanced from a ipsilateral femoral approach

(Atrium Hudson NH USA) on the right and a 7mm times59mm iCAST balloon expandable covered stent on theleft deployed simultaneously in a kissing fashion the iliacstents were extended further to cover the entire length of theoccluded common iliac arteries ending just above the iliacbifurcations Final arteriogram showed reestablishment offlow through the reconstructed aortoiliac bifurcation withno significant residual stenosis (Figure 7) The patient wasdischarged the next day on Clopidogrel 75mg once a dayfor 3 months and aspirin 325mg once a day for life Shenoted significant clinical improvement with an ABI of 085on the right and 101 on the left at her 2-week postprocedurefollowup She was seen in followup at 6 months withrecurrence of intermittent claudication on the right after15 minutes of walking Her right ABI decreased to 069her left ABI was stable and measured 105 A CTA showedsevere stenosis at the proximal aspect of the right CIA stentHer symptoms were subjectively described as mild andnondisabling and she declined any further intervention

3 Discussion

The standard of care in patients with total aortoiliac occlusionis surgical and includes endarterectomy graft insertion andanatomic or extra-anatomic bypass all considered majorinterventions [1 3 5] Consequently these patients are oftendenied surgery and remain untreated for a long time

In a small series of 11 patients with total aortoiliacocclusion treatedwith endovascular reconstruction bilateralsuccess was achieved in 8 patients (73) Unilateral successwith recanalization of only one iliac artery was achieved inthe remaining 3 patients (27) At the median followup of

Figure 5 Wire retrieval from the left femoral sheath followingrecanalization of the left common iliac artery

Figure 6 Deployment of the balloon expandable stent in the distalaorta

14 months all patients were alive and reported marked reliefof symptoms with improvement in clinical status by at leastone Rutherford category Pending long-term outcomes andexperience with a greater number of patients the endovas-cular approach holds promise to replace surgery as the firstline of treatment in patients with extensive aortoiliac disease[1] Percutaneous Intentional Extraluminal Recanalization(PIER) can be safely performed in the iliac territory Thereentry level from a femoral retrograde approach into theaorta can be unpredictable however and the risk of extendingthe subintimal dissection into a patent aortic segment is realThis situation has been described as one of themost commonreasons for failure [6] Therefore many interventionalistsprefer the brachial approach [7] Once one of the occludediliac arteries is recanalized crossing the contralateral iliac


Figure 7 Reconstruction of the aortoiliac occlusion with an aorticstent and bilateral kissing iliac stents

occlusion from a brachial approach can become more chal-lenging as the wire and catheter will follow the path ofthe least resistance into the recanalized iliac segment Aguiding sheath can provide support for the wire and catheterduring recanalization in the setting of flush CIA occlusionor aortoiliac occlusion without a stump at the origin of theCIA the guiding sheath can have difficulty engaging with thelesion and the advantage of using the stiff support of theguiding sheath is negated [8] The crossover recanalizationapproach is another alternative where a curved diagnosticcatheter advanced from a contralateral femoral approachis positioned at the aortic bifurcation with the tip engagingthe stump of the iliac occlusion A hydrophilic angled-tipGlidewire (Terumo Somerset NJ USA) is used to cross theiliac occlusion and externalized through a sheath placed inthe CFA ipsilateral to the treated CIA Again this techniqueis limited in flush iliac and complete aortoiliac occlusions asby definition there is no iliac stump to engage with [9]

A curved sheathed needle can be used to puncture intothe true lumen of the aorta from the subintimal tract duringrecanalization of the CIA from an ipsilateral retrogradeapproach [10] In brief the technique consists of placing anocclusion balloon in the true lumen of the distal abdominalaorta advanced through the patent contralateral iliac systemusing a femoral approach An 18-guage curved sheathed-needle is advanced through the ipsilateral subintimal tract ofthe iliac artery the needle is sheathed at this point and usedto indent the occlusion balloon and then advanced furtherrupturing the balloon A wire is advanced through the needleonce the position in the true lumen of the distal aorta isconfirmed [11]

Re-entry into the true lumen can be facilitated by reentrydevices like the Outback LTD catheter (Cordis Miami LakeFL USA) and Pioneer catheter (Medtronic CardiovascularSanta Rosa CA USA) The initial experience primarilyobtained in the femoral arteries supports their clinical value

Experience with these technologies in the iliac arteries isstill somewhat limited however a few small series reportedhigh technical success rate with these devices in the aortoiliacterritory [12 13]

A recently published technical note described recanal-ization of a flush iliac occlusion with the assistance of acontralateral iliac occlusive balloon in a patientwith a chronictotal occlusion of the left CIA the distal abdominal aorta andright CIA were patent [8] We used a very similar techniqueour patient however had a total aortoiliac occlusion

4 Conclusion

Endovascular recanalization of a total aortoiliac occlusion istechnically challenging with the inability to reenter the truelumen at the level of the aorta being one of themost commoncauses of failure when attempted from a femoral approachA brachial approach can offer some advantage but once anoccluded iliac artery is recanalized crossing the contralateraliliac occlusion could become more challenging as the wireand catheter tend to follow the path of least resistance to therecanalized iliac artery Placement of a contralateral occlusionballoon could assist in recanalizing the other iliac occlusionThe real value of this technique is yet to be determined in alarger series with reproducible results

Abbreviations

CIA Common iliac arteryEIA External iliac arteryCFA Common femoral arteryACT Activated clotting timeTASC Trans-Atlantic Inter-Society ConsensusABI Ankle-brachial indexCTA Computed tomographic angiography

Conflict of Interests

The author declares no conflict of interests

References

[1] H Krakenberg M Schluter C Schwencke et al ldquoEndovascularreconstruction of the aortic bifurcation in patients with Lerichesyndromerdquo Clinical Research in Cardiology vol 98 no 10 pp657ndash664 2009

[2] M Piazza J J Ricotta T C Bower et al ldquoIliac artery stentingcombined with open femoral endarterectomy is as effectiveas open surgical reconstruction for severe iliac and commonfemoral occlusive diseaserdquo Journal of Vascular Surgery vol 54no 2 pp 402ndash411 2011

[3] L Norgren W R Hiatt J A Dormandy M R Nehler K AHarris and F G R Fowkes ldquoInter-society consensus for themanagement of peripheral arterial disease (TASC II)rdquo Journalof Vascular Surgery vol 45 no 1 supplement pp S5ndashS67 2007

[4] V S KashyapM L Pavkov J F Bena et al ldquoThemanagement ofsevere aortoiliac occlusive disease endovascular therapy rivalsopen reconstructionrdquo Journal of Vascular Surgery vol 48 no 6pp 1451e3ndash1457e3 2008


[5] T Sugimoto K Ogawa T Asada et al ldquoLeriche syndromesurgical procedures and early and late resultsrdquo Angiology vol48 no 7 pp 637ndash642 1997

[6] D Vorwerk R W Guenther K Schurmann G Wendt andI Peters ldquoPrimary stent placement for chronic iliac arteryocclusions follow-up results in 103 patientsrdquoRadiology vol 194no 3 pp 745ndash749 1995

[7] D Scheinert and A Schmidt ldquoTechniques for crossing iliac andaortoiliac CTOs Using access strategies and reentry devices forsuccessful interventionrdquo Endovascular Today vol 10 pp 39ndash432011

[8] C F Bechara N R Barshes P H Lin and P KougiasldquoRecanalization of flush iliac occlusions with the assistanceof a contralateral iliac occlusive balloonrdquo Journal of VascularSurgery vol 55 no 3 pp 872ndash874 2012

[9] D Scheinert M Schroder J Ludwig et al ldquoStent-supportedrecanalization of chronic iliac artery occlusionsrdquo AmericanJournal of Medicine vol 110 no 9 pp 708ndash715 2001

[10] T P Murphy and D Vorwerk ldquoAdvanced aortoiliac interven-tionsrdquo Techniques in Vascular and Interventional Radiology vol3 no 4 pp 195ndash207 2000

[11] T P Murphy M J Marks and M S Webb ldquoUse of acurved needle for true lumen re-entry during subintimal iliacartery revascularizationrdquo Journal of Vascular and InterventionalRadiology vol 8 no 4 pp 633ndash636 1997

[12] G Ramjas P Thurley and S Habib ldquoThe use of a re-entrycatheter in recanalization of chronic inflow occlusions of thecommon iliac arteryrdquo Cardiovascular and Interventional Radi-ology vol 31 no 3 pp 650ndash654 2008

[13] H Al-Ameri V Shin G S Mayeda et al ldquoPeripheral chronictotal occlusions treated with subintimal angioplasty and a truelumen re-entry devicerdquo Journal of Invasive Cardiology vol 21no 9 pp 468ndash472 2009

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Figure 1 Aortogram showing total occlusion of the distal abdomi-nal aorta and bilateral common iliac arteries

Figure 2 Aortogram showing reconstitution at the level of the iliacbifurcations

access kit (CookMedical Bloomington INUSA)A 5 Frenchsheath was placed and a 5 French pigtail flush catheter (CookMedical Bloomington IN USA) was advanced into theabdominal aorta An aortogram was performed and showedcomplete occlusion of the distal infra-renal aorta andbilateral CIAs with reconstitution at the iliac bifurcations(Figures 1 and 2) Bilateral retrograde common femoral artery(CFA) access was obtained using ultrasound guidance and amicropuncture access kit Five French sheaths were insertedin the CFA bilaterally and upsized later to an 8 Frenchsheath on the left and 7 French on the right Unfractionatedheparin was injected intravenously in boluses throughout theprocedure tomaintain the activated clotting time (ACT)gt250seconds A 5 French Davis catheter (Cook Bloomington INUSA) and 003510158401015840 Glidewire (Terumo Somerset NJ USA)were used to perform antegrade subintimal recanalization ofthe right CIA from a brachial approach The Glidewire was

Figure 3 Wire retrieval from the right femoral sheath followingrecanalization of the right common iliac artery

retrieved from the right femoral sheath (Figure 3) and thenexchanged for a Rosen wire (Cook Bloomington IN USA)Subintimal recanalization of the left CIA from a femoralapproach was unsuccessful with failure to reenter the trueaortic lumen Attempts to recanalize the left CIA from abrachial approach were also unsuccessful as the wire andcatheter continued to advance into the recanalized rightCIA following the path of the least resistance To overcomethis problem the recanalized right CIA was occluded at itsorigin with a 5mm times 40mm UTD balloon catheter (BostonScientific Natick MA USA) inserted from the right femoralapproach sealing the origin of the right CIA The 5 FrenchDavis catheter was advanced from the brachial approach intothe distal abdominal aorta to the level of the occluded leftCIAWith the tip of the catheter pointed toward the occludedleftCIA the stiff back end of a 003510158401015840Glidewirewas advancedto initiate a sharp recanalization of the occluded left CIA(Figure 4) The presence of the occlusion balloon preventedthe Davis catheter from advancing into the recanalized rightCIA and forced it in the direction of the occluded left CIAThe catheter was advanced over the wire into the occludedleft CIA At this point the floppy end of the Glidewire wasadvanced through the catheter and recanalization of the leftCIA continued from a brachial approach The wire reenteredthe true lumen of the left EIA and was retrieved from the leftfemoral sheath (Figure 5) The Glidewire was exchanged fora Rosen wire advanced into the abdominal aorta From theleft femoral approach a 16mm length Intrastent DoublestrutLD balloon expandable stent (EV3 Plymouth MN USA)mounted on 10mm times 2 cm EverCross balloon catheter(EV3 Plymouth MN USA) was deployed in the proximaloccluded aortic segment and then further balloon dilatedto 12mm using a 12mm times 2 cm EverCross balloon catheter(EV3 Plymouth MN USA) (Figure 6) More distally theoccluded aortoiliac bifurcation was reconstructed using a6mm times 59mm iCAST balloon expandable covered stent




3 Discussion













4 Conclusion


Abbreviations




References




















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Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















3 Discussion













4 Conclusion


Abbreviations




References




















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of























4 Conclusion


Abbreviations




References




















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















case report balloon occlusion of the contralateral iliac...

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