Chapter 108 - Aortoiliac disease endovascular treatment

Question 1

Balloon angioplasty was developed by

Answer 1

Dotter and Gruntzig

Question 2

Threshold for significant systolic gradients

Answer 2

Resting systolic > 10 mmHg Vasodilator-enhanced gradient > 20 mmHg

Question 3

Relative contraindication to endovascular treatment of AIOD

Answer 3

1) juxtarenal aortic occlusion 2) circumferential calcification >1mm 3) hypoplastic aortic syndrome 4) juxtaposition to aneurysmal disease 5) renal insufficiency

Question 4

Definition of contrast induced nephropathy

Answer 4

Increase in Cr > 25% or > 44.2 increase within 3 days of contrast in absence of alternative cause

Question 5

How long does it take for contrast induced nephropathy to return to baseline

Answer 5

14 days

Question 6

Concerns of contrast induced nephropathy in terms of baseline GFR

Answer 6

eGFR > 60 rare 40-45 concerned < 30 very concerned

Question 7

Key points on the risk of contrast induced nephropathy and dosing

Answer 7

1) Precaution for eGFR < 60 in IA admin 2) precaution for eGFR < 45 in IV admin 3) keep total volume < 5ml/kg 4) second dose within 48 hours increase risk (should wait 72 hours) 5) withhold diuretics on day of contrast injection

Question 8

Number needed to treat with sodium bicarb to prevent contrast induced nephropathy

Answer 8

8.4 patients

Question 9

Number needed to treat with acetylcysteine to prevent contrast induced nephropathy

Answer 9

no evidence that it works

Question 10

Sodium bicarbonate bolus and infusion to prevent contrast induced nephropathy

Answer 10

Bolus 3 ml/kg/hr (154 mEq/L NaHCO3 in dextrose and water) for 1 hour before contrast then at 1 ml/kg/hr during contrast use and another 6 hours after

Question 11

Dose of vasodilator for measuring significant lesions

Answer 11

Nitroglycerin 100-200 mcg Papaverine 25 mg

Question 12

Maximum increase in pressure gradient occurs this much time after injection of vasodilator

Answer 12

20-40 seconds

Question 13

Describe outback reentry catheter

Answer 13

LuMend Inc 1) single lumen 2) retractable needle to gain access

Question 14

Describe Pioneer catheter

Answer 14

Medtronic 1) IVUS

Question 15

Techniques to recanalize CTO in iliac

Answer 15

1) contralateral 2) brachial 3) reentry wire/catheters

Question 16

Amount of stent oversizing in iliac artery

Answer 16

5-10%

Question 17

Measurement of treatment success after stenting iliac artery

Answer 17

<20% residual stenosis <10 mmHg systolic pressure gradient

Question 18

Benefit of balloon-expandable stent/grafts

Answer 18

1) precision of placement 2) high radiopacity 3) high hoop strength

Question 19

Benefit of self-expanding stent/graft

Answer 19

1) flexible

Question 20

Iliac POBA patency

Answer 20

44-65% 4 years

Question 21

Complication of iliac angioplasty

Answer 21

1) dissection 2) closure 3) spasm 4) thrombus formation 5) embolization

Question 22

Patency of kissing iliac stents (primary and secondary)

Answer 22

78% primary 98% secondary

Question 23

Dutch iliac stent trial study group

Answer 23

1) POBA +/- stent vs primary stent 2) 43% in POBA group got stented 3) no difference between the two groups 4) reintervention ~20%

Question 24

Metaanalysis on primary stenting vs selective stenting

Answer 24

1) 1300 patients 2) technically success > 90% with primary stenting 3) primary patency > 70% at 2-5 years with stenting 4) 4 year patency in claudicant 68% POBA vs 77% stent 5) 4 year patency in CLTI 55% POBA vs 67% stent

Question 25

Murphy long term results 18 studies on iliac stenting or plasty

Answer 25

1) tech success 97% 2) complication rate 6% 3) 5 year primary patency 73%; secondary 85%

Question 26

Schurmann 10 year follow up iliac stenting

Answer 26

1) primary patency 66% at 5 years; 46% at 10 years 2) secondary patency 79% at 5 years; 55% at 10 years 3) restenosis 41% in 3.9 years

Question 27

When and why should metformin be held to avoid contrast induced nephropathy

Answer 27

1) 48 hours 2) lactic acidosis rare complication can worsen AKI

Question 28

Galaria on 10 year patency with TASC lesion classes A+B

Answer 28

1) 77% claudicants 2) 62% TASC A, 38% TASC B 3) mortality 1.8% 30 days; 4.7% 90 days 4) complication 7% 5) hemodynamic success 82% (ABI > 0.15) 6) primary patency 71% 10 years 7) two vessel femoral runoff or 2+ tibial vessel improved patency 8) limb salvage rate 95% 5 years and 87% 10 years

Question 29

de Vries and Hunink Metaanalysis on iliac stent patency 1970-1996

Answer 29

Claudication: 5 year 91%; 10 year 86.8% CLTI: 5 year 88%; 10 year 82%

Question 30

Primary patency for TASC C+D with endo

Answer 30

60-86% 5 year

Question 31

Secondary patency for TASC C+D with endo

Answer 31

80-98% 5 year

Question 32

Successful recanalization in TASC C+D iliac lesions

Answer 32

90%

Question 33

Hybrid femoral treatment and iliac endo 5 year patency

Answer 33

Primary: 60% Primary assisted 97% Secondary 98%

Question 34

Stent graft vs bare stents in iliac disease patency

Answer 34

87% vs 53%

Question 35

1 year patency in EIA disease with bare stent

Answer 35

47%

Question 36

Predictors of bad outcome in iliac stenting

Answer 36

1) female 2) renal insufficiency 3) CLTI

Question 37

Primary patency at 6 and 12 months in patients treated with iliac endo alone vs those with FEA as well

Answer 37

FEA + iliac plasty 94% 6 months; 94% 12 months iliac plasty alone 79% 6 months; 53% 12 months

Question 38

Primary patency at 3 and 5 year for iliac stent graft

Answer 38

80% at 3 and 5 years primary patency 95% primary assisted patency at 3 and 5 years

Question 39

Primary patency in TASC lesion in iliac stent graft

Answer 39

TASC B: 100% 5 year patency TASC C: 61% TASC D: 85%

Question 40

COBEST trial

Answer 40

1) Mwipatayl et al 2) bare metal vs stent graft in AIOD 3) 5 year patency TASC C+D: 50% stent vs 95% graft 4) TASC B no difference

Question 41

all cause mortality in claudicants at 5, 10, 15 years

Answer 41

30% - 5 years 50% - 10 years 70% - 15 years

Question 42

Cause of death in PAD patients

Answer 42

40-60% CAD 10-20% CVA 10% other vascular causes (mainly ruptured aneurysm) 20-30% non-vascular (mainly cancer)

Question 43

Schumann et al mortality at 5 and 10 years following iliac stenting

Answer 43

17% at 5 year 36% at 10 years

Question 44

Local complication rate in iliac stent

Answer 44

1-3%

Question 45

Rate of arterial rupture in iliac stent

Answer 45

<1%

Question 46

recommended follow up after iliac plasty

Answer 46

1 month then 6 months

Question 47

Restenosis on duplex as a measure from peak systolic velocity

Answer 47

Doubling of peak systolic velocity = restenosis

Question 48

Aortoiliac lesions

TASC classifications

Answer 48