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P. Goverde MD,
K. Taeymans MD, L. Helsloot MD, K. Lauwers MD, P. Verbruggen MD
Vascular Clinic ZNA, Antwerp,Belgium
Advanced techniques
for complex
aortoiliac
obstructions
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Diclosure
Speaker’s name: Peter Goverde I have the following potential conflicts of interest to report:
Consulting:
Abbott Vascular; Angioslide; Atrium Maquet Getinge
group; Bard Peripheral Vascular; Cardionovum; Cordis Cardinal Health; IMDS; Ivascular; Stille;
Veyran; Ziehm Imaging
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Aorto-iliac occlusive disease
“Cerab-technique : a new approach in treating extensive aortoiliac occlusive disease”Goverde P. Grimme F, Reijnen M., et al ; J Cardiovasc Surg 2013;54:383-7
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Important
Infrarenal aorta
Aortoiliac bifurcation
Iliac region
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Extensive aortoiliac disease
•Double barrel bare metal stents ± stents in the renalarteries
•Use of AAA devices
•Covered endovascularreconstruction (CERAB)
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Extensive aortoiliac disease
•Double barrel bare metal stents ± chimney in the renalarteries
•Use of AAA devices
•Covered endovascularreconstruction (CERAB)
courtesy of Dr Mangialardi-Ronchey, San Filippo Neri Hospital, Rome
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Extensive aortoiliac disease
•Double barrel bare metal stents ± stents in the renalarteries
•Use of AAA devices
•Covered endovascularreconstruction (CERAB)courtesy of Dr Mangialardi-Ronchey,
San Filippo Neri Hospital, RomePrestented at the Veith Symposium 2012
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Extensive aortoiliac disease
•Double barrel bare metal stents ± stents in the renalarteries
•Use of AAA devices
•Covered endovascularreconstruction (CERAB)
Maynar M. et al. J Endovasc Ther 2005;12:22-27
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Possible Disadvantages CERAB configuration
• LD-covered stents not everywhere and always available
• Maximum flairing capacity
• Cannulation of LD covered stent can be difficult (brachial approach)
• Radial mismatch depending on operator experience technical imperfection
Groot Jebbink et al. J Vasc Surg, 2014 Jan 29..
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Endologix AFX Stent Graft
• Unibody design for AAA repair (EVAR)
• Sits on the aortic bifurcation
• Sizes from 22mm to 28mm with various
iliac sizes and lengths
• Low 17F profile (percutaneous)
• Percutaneous approval
Role in Aortoiliac Occlusive Disease?
Courtesy of Dr Michel Reijnen MD
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AFX : Advantages for AIOD
• Preserves aortic bifurcation
• No limb competition in a narrow distal aorta
• Avoid the possibility of ‘missing’ CIA lesion
• Does not preclude future aortic interventions
• Protective in cases of potential rupture
• Fabric allows for significant
oversizing without wrinkle /infolding25mmAFX
Courtesy of Dr Michel Reijnen MD
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Extensive aortoiliac disease
•Double barrel bare metal stents ± stents in the renalarteries
•Use of AAA devices
•Covered endovascularreconstruction of Aortic
Bifurcation (CERAB)
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How to start ?
P. Goverde MD; Vascular Surgeon,Vascular Clinic ZNA
ZNA Stuivenberg Hospital, Antwerp, Belgium
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Points
of ATTENTION
Tips & Tricks
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Midaortic juxtarenal lesions
Risk of occluding visceral arteries Embolisation of débris Overstenting Coral reef encroachment
1 Chimney grafts preserve visceral flow and allow safe stenting of juxtarenal aortic occlusion Adel Bin Jabr, MD, Björn Sonesson, MD et al. J Vasc Surg 2013;57:399-405
1
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Brachial access
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Brachial access
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Chimney - CERAB
• General anesthesia
• Percutaneous access: bifemoral & uni/bilateral brachial
• Antegrade recanalisation aortoiliac axes
• Catheterisation of visceral arteries (brachial)
V12 balloon expandablecovered stents Atrium Maquet Getinge Europe BV
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Chimney - CERAB
• Aorta: 12x61 mm V12 balloon expandable stent-graft (Atrium
Maquet Getinge Europe BV)
• Expansion of visceral stents (6x38 mm)
• Expansion of aortic stent
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Angio control after 18 months
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Outback re-entry device Cordis Cardinal Health
Re-entry failure afterballoon attempts
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Outback useRe-entry failure afterballoon attempts
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Outback useRe-entry failure afterballoon attempts
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Common Iliac Artery calcification
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Common Iliac Artery calcification
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Common Iliac Artery calcification
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Common Iliac Artery calcification
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Occluded external iliac stents
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Occluded external iliac stents
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Occluded external iliac stents
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Occluded external iliac stents
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Occluded external iliac stents
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Occluded external iliac stents
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Possible technical problem: replacement of 2’ guide wire in to aortic stent
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Possible technical problem: replacement of 2’ guide wire in to aortic stent
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Possible technical problem: replacement of 2’ guide wire in aortic stent : CONTROL !!!!
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Possible technical problem: replacement of 2’ guide wire in to aortic stent
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Technical considerationsWhat’s on the
market
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Different possible CERAB configurations with BX covered
stents
Courtesy of Peter Goverde MD
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Different possible CERAB configurations
• Future CERAB made of :• Main body :
– BeGraft Aortic Bentley Bx– Diameters 12-14-16-18-20-22-24mm– Largest Can been postdilated up to max 28
mm– Length :– 19-28- 37-57mm
• Legs: – BeGraft Bentley Bx Bx– Diameters 6 to 10mm– Length : 28 (27)-38(37)-58(57)
• Can be postdilated• Less shortening
–Courtesy of Peter Goverde MD & Bentley
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Different possible CERAB configurations
• CERAB made of :• Main body :
– V12 Maquet Getinge Bx
– Diameters 10-12-14-16 mm
– Length :
– 10 : 38 & 59 mm
– 12-14-16 : 41 & 61 mm
• Legs:
– V12 Maquet Getinge Bx
– Diameters 6 to 9 mm
– Length : 38 & 59 mm
• Can be postdilated
• Cave shortening
–Courtesy of Peter Goverde MD
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Different possible CERAB configurations
• CERAB made of :• Main body :
– LifeStream Bard PV Bx
– Diameters 10-12 mm
– Can been postdilated to 16 mm
– Length :
– 38 & 58 mm
• Legs:
– LifeStream Bard PV Bx
– Diameters 6 to 9 mm
– Length : 37 (38 for 9mm) & 58 mm
• Can be postdilated
• Less shortening
–Courtesy of Peter Goverde MD
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Different possible CERAB configurations
• CERAB made of :• Main body + bifurcation:
– AFX main body Endologix
– Diameters 22 mm
– Length : 40 or 60 mm
• Legs: – V12 Maquet Getinge Bx
– LifeStream Bard PV
– Fluency Plus Bard PV
– Viabahn Gore
• Can be an alternative if rest is not available
• For larger reconstructions–Courtesy of Dr Peter Goverde MD
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Preclosing with Proglide(Abbott vascular)
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Preclosing with Proglide(Abbott vascular)
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Be carefull with percutaneous closure
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Conclusions
• Safe and feasible techniques
• “Sufficient” distal outflow is recommended/needed
• Awareness of some tips & tricks
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P. Goverde MD,
K. Taeymans MD, L. Helsloot MD, K. Lauwers MD, P. Verbruggen MD
Vascular Clinic ZNA, Antwerp,Belgium
Advanced techniques
for complex
aortoiliac
obstructions