SelfExpanding Covered or BalloonExpandable Stenting for Common Iliac

Self-Expanding, Covered or Balloon-Expandable Stenting for Common Iliac Lesions James P. Zidar, M. D. , F. A. C. C. , F. S. C. A. I Clinical Professor of Medicine UNC Health Systems Corporate Chief of Cardiology, Rex Healthcare President, Rex Heart and Vascular Specialists Raleigh, North Carolina

James P. Zidar, MD Grant Support: Cordis Corporation Honoraria: Medtronic Core. Valve Abbott Vascular

Aorto Iliac Lesions Primary and secondary cumulative patency rates at 36 months were 79. 4% and 97. 7%, respectively. J Endovasc Ther. 2002 Jun; 9(3): 363 -8 Balloon-expandable stents had a non-significant trend towards higher patency rates compared to selfexpanding stents.

How do you make a diseased iliac artery as normal as possible?

Benefits of Self-Expandable: Distal External Iliac Lesions Flexibility and long lengths, 6 Fr compatible

Iliac Stent Tips: Watch Out for Pseudolesions From Vessel Kinking • Stiff guidewire causing Real Lesion • Fake • • pseudolesions Easy to lose track which is the true lesion Left common iliac stented When in doubt, put soft catheter in and inject

Iliac stent options • Balloon expandable stents • • Precise placement, approach ipsilateral Best for Common iliac and aortic bifurcation lesions. Excellent radial strength Often need 7 Fr sheath • Self-expanding stents • Best for long lesions, ectasia, external iliacs. • Can approach ipsi- or contra-lateral • Can place a 10 mm stent in a 6 Fr sheath or 5 Fr (Cook) • Covered stents • Best for ISR, ectasia or perforation. • Requires larger 7 -10 Fr sheaths.

Iliac case • 54 year old smoker with HTN and dyslipidemia • Bilateral leg weakness and claudication for 4 mon • LE Arterial Duplex suggests severe bilateral inflow disease with minimal SFA-pop disease and 3 vessel runoff • ABIs: right. 41 and left. 53 • No CLI • No rest pain

Baseline images

Options 1. Send for aorto-bifemoral bypass 2. PTA and Stent left common iliac and send for fem-fem jump graft 3. Attempt to recanalize right iliac and perform bilateral iliac stenting • Considerations: • Age, functional status, durability, calcium, technical difficulty, patient’s preference

After 8 x 24 mm Genesis stent • Location ? • Size • Length • Runoff

Strategies • Cross CTO from below • Cross from above • Kissing balloons at bifurcation ? • Size • Length

Details • 6 Fr 22 cm Cordis Britetip sheath in right CFA • . 035” Quick. Cross • . 035” Glidewire • Sub-intimal to distal aorta • Options?

Details - 2 • Advanced. 035” Glidewire through Omniflush diag catheter • Pulled right sheath back to ext iliac • Advanced wire into sheath • Externalized wire

Details - 3 • Advanced 5. 0 x • • 60 mm Fox Plus balloon up R sheath without difficulty and into left ext iliac Pulled wire from L groin and advanced. 0035” J wire thru balloon via right groin Advanced a new. 035” J wire up L sheath to aorta

Details - 4 • Dilate right common • • iliac with 5 x 60 mm Fox Plus balloon What next? Stent • BE or SE

Details - 5 • Deploy 7 x 59 mm • Cordis Genesis stent in R common iliac Protect left common iliac with 7 x 40 mm Fox Plus balloon using kissing inflation

7 x 60 mm Absolute Pro in R EIA and dilate with 6 x 60 Fox Plus balloon to 10 atm

Final

Iliac case: follow-up • Seen in clinic 7 months out • Quit smoking and gained 10 lb. • Only 5’ 3’‘ and 136 lb. • No claudication, occ nocturnal leg cramps • Six month LE arterial Duplex notes ABIs of: • Right. 91, left. 92.