Endovascular reconstruction of iliac artery bifurcation atherosclerotic disease with the kissing technique

Introduction

Intentional sacrifice of one or both internal iliac arteries (IIAs) during aortoiliac aneurysm repair may lead to a wide variety of symptoms, including hip and buttock claudication, colonic ischemia, perineal or spinal ischemia, sexual impotence and buttock necrosis. ¹ In particular, patients with insufficient collateral flow to the inferior mesenteric artery are at increased risk for such complications, ² thus justifying preservation of IIA patency during angioplasty or stenting of the common or external iliac artery.

We present herein a patient with a tight stenosis of the orifice of the left external iliac artery (EIA), which caused severe left lower-extremity claudication and a severe stenosis of the ipsilateral IIA origin resulting in significant buttock claudication. In such disease patterns, stenting of the EIA lesion may require stent coverage of the distal aspect of the common iliac artery. Such an approach, however, results frequently in a ‘stent-jailed’ IIA orifice, which often leads to either immediate or later occlusion of the artery with the aforementioned possible clinical manifestations. To avoid such an effect, we used a modified ‘kissing’ technique, based on the commonly used ‘kissing’ angioplasty or stenting for lesions of the aortic bifurcation,^3–5 aiming to treat at the same time both symptomatic stenoses of the EIA and IIA orifices and avoid collapse of the IIA origin during EIA stent deployment.

Case report

A 71-year-old fit very active man with severe left hip and buttock claudication (<100 m, stage Fontaine II) for the last six months was referred to our department for evaluation and possible endovascular treatment. Medical history included hypertension, smoking and coronary artery disease with stenting and bypass operation three years before. Clinical examination revealed a left ankle–brachial index (ABI) of 0.5. The patient had been examined with color duplex scanning by his primary care physician, which demonstrated an 85% EIA stenosis. Digital subtraction angiography was subsequently performed that revealed left EIA and IIA artery stenoses of 90% with poststenotic dilation (Figure 1). OPEN IN VIEWER

In view of the patient's good level of activity and his age, we decided to attempt a complete endovascular reconstruction of the iliac bifurcation aiming to preserve the IIA during EIA stenting, using the ‘kissing’ technique.

Under local anaesthesia, the left iliac artery bifurcation was approached percutaneously through bilateral femoral accesses. A standard crossover technique was used for catheterization of the left IIA (via right femoral artery). A stiffer wire (Amplatz Super Stiff, Cook, Bloomington, IN, USA) was then inserted and an angioplasty balloon catheter 5 mm × 20 mm (Sterling™ Balloon Dilatation Catheter, Boston Scientific, Natick, MA, USA) was advanced into the left IIA through a long contralateral sheath (6 Fr, 45 cm, Destination® Guiding Sheath, ©Terumo Europe N.V., Leuven, BE). A balloon expandable stent-graft 9 mm × 30 mm (Express® LD Iliac Premounted Stent System, Boston Scientific, Natick, MA, USA) was delivered through the left femoral access and was advanced at the level of left EIA origin. After angiographic imaging of the narrowed arterial segments, both balloons were inflated simultaneously with the ‘kissing’ technique (Figure 2). A completion angiogram demonstrated successful restoration of both vessels patency (Figure 3). ABI was increased to 0.9 immediately after the procedure. OPEN IN VIEWER

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Figure 3

A completion angiogram demonstrated complete restoration of both vessels patency

During intervention, the patient received 5000 IU heparin intravenously. The procedure lasted 20 minutes with fluoroscopy time of nine minutes and total contrast volume used of 30 mL (Visipaque 270 mg/mL, GE Healthcare B.V., Eindhoven, The Netherlands).

The patient's recovery was uneventful. Renal function remained unchanged. The patient was discharged home on the first postoperative day. He received a combination of clopidogrel (75 mg/day for 4 weeks) and acetylsalicylic acid (100 mg/day) lifelong. At 12 months, the patient is doing well, without buttock or lower-extremities claudication. ABI remains at a normal value (0.9) and color duplex examination reveals a patent left EIA and IIA without re-stenosis (Figure 4). The patient will continue duplex follow-up on a six-month basis, or earlier in case that symptoms’ recurrence is noticed. OPEN IN VIEWER

Discussion

During the last decade, several cohort series have been published demonstrating the feasibility of ‘kissing’ technique in common iliac artery stenting, which is the only totally endovascular method to treat aortic bifurcation disease.^3–5 Endovascular treatment reduced mortality and both rate and severity of complications and has rapidly replaced open surgery for aortoiliac occlusive disease. ³

In the herein presented case we applied a modified ‘kissing’ technique in the common iliac artery bifurcation in order to repair an orifice EIA tight stenosis preserving, however, at the same time the ipsilateral IIA. Via a standard crossover approach and an ipsilateral retrograde femoral access we performed simultaneous dilations at the IIA and EIA with two balloons (diameters, 5 and 9 mm, respectively) one bare and the second within a stent to achieve an optimal expansion and avoid occlusion of the narrowed IIA origin during EIA stenting.

Failure to preserve the IIA during endovascular aorto-iliac interventions has been associated with significant complications including buttock claudication or necrosis, colonic ischemia, perineal or spinal ischemia and impotence, and therefore several authors favor an attempt for IIA salvage. ⁶ Furthermore, many investigators advocate the value of IIA revascularization for the treatment of buttock claudication symptoms, highlighting the superiority of direct revascularization approaches (percutaneous transluminal angioplasty and internal iliac artery bypass), compared with indirect ones (aortobifemoral bypass and recanalization of the femoral junction on the ischemic side, resulting in indirect inflow from collateral arteries in the hypogastric territory). ⁷ The kissing technique presented herein is a useful approach both for preserving the IIA during proximal EIA stenting and for achieving direct recanalization of the IIA and EIA, leading thus to resolution of both buttock and lower-extremity ischemic symptoms with an one-stage relatively simple intervention.

Such a technique should be applied in selected patients who meet specific criteria. First, the IIA has to be patent despite the presence of a critical stenosis. Second a sharp aortic bifurcation could pose difficulties in the contra-lateral approach, although in that case the balloon in the IIA could alternatively be inserted through a brachial artery catheterization. The technique should also be offered only to patients with a sufficient activity level. Indeed, direct re-vascularization of the IIA, if feasible, provides the best functional outcome for prevention of buttock claudication.^7,8 Therefore, preservation of the left IIA flow was considered important in our relatively fit and active patient.

In general, when we have to treat a lesion at the origin of the IIA, we routinely place two wires (1 into the IIA and the other into the EIA) as we did in this patient. In cases that the EIA also has significant disease, as in this case, we simultaneously stent the EIA while ballooning the IIA. We prefer to stent the IIA only in the presence of severely calcified lesions or in cases that a significant residual stenosis is noticed after angioplasty. With such a strategy we avoid jeopardizing the EIA in the event the IIA stent is placed more proximally than intended. In the case of an EIA with minimal disease and no symptoms of lower-limb claudication, we do not routinely stent the EIA, but we keep the wire in place in case that IIA angioplasty/stenting causes compromization of the EIA origin. In the latter case we proceed also with EIA stenting.

It is to mention that in the herein presented patient the distal portion of the right IIA appears to have also a stenosis. Since, however, the patient was totally asymptomatic from this side we decided not to treat this stenosis as well. Besides, in cases of bilateral IIA disease with buttock claudication symptoms in both sides, we do not routinely treat both sides at the same procedure, but we wait and see if symptoms improve after treatment of only one side. Many times, dilation of only one IIA is adequate and improves symptoms in both sides probably through collateral circulation between the two hypogastric arteries.

Conclusion

Preservation of the IIA during angioplasty and stenting of the proximal EIA has to be considered in active, generally fit patients. The ‘kissing’ technique as described herein offers a complete endovascular iliac bifurcation reconstruction avoiding occlusion of the IIA and the consequent potential deleterious clinical complications associated with such an effect.