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P. Goverde MD,
Antwerp,Belgium
Covered
Endovascular
Reconstruction
Aortic
Bifurcation

Better then bare stenting for
aortoiliac occlusive disease
????

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Covered
Endovascular
Reconstruction
Aortic
Bifurcation
CERAB cuff & kiss
A new technique
to reconstruct
the aortic bifurcation with
3 Atrium Advanta V12
covered stents
for occlusive disease
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How to treat ?
How to prevent ?
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Kissing stent technique
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Results kissing stents for the treatment of complex
or extensive aortoiliac occlusive disease not always
satisfactory

poor patency due to:

thrombus formation

neointimal hyperplasia
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protrusion of kissing stents into
the distal aortic lumen creates
a new flow divider

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protrusion of kissing stents into the distal
aortic lumen creates a new flow divider

gives rise to

presence of immature mesenchymal tissue
intimal hyperplasia
organizing thrombus

where is this situated ?

in the space between the opposing stents
within the lumen of the stents
at the level of the free floating intra-aortic
portion of the devices







Saker M. B. , Oppat W. F. , and Kent S. A. . et al.
Early failure of aortoiliac kissing stents: histopathologic correlation.
J Vasc Interv Radiol 2000. 11:333336.
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protrusion of kissing stents into
the distal aortic lumen creates
a new flow divider

Saker MB, Oppat WF, Kent SA et al
Early failure of aortoiliac kissing stents: histopathologic correlation.
J Vasc Interv Radiol 2000. 11:333-336

Sharafuddin MJ, Hoballah JJ, Kresowiki TF, et al.
Long-term outcome following stent reconstruction of the aortic
bifurcation and the role of geometric determinants.
Ann Vasc Surg 2008; 22:346-357

Greiner A, Mhlthaler H, Neuhauser et al.
Does stent overlap influence patency rate of aortoiliac kissing stents?
J Endovasc Ther 2005; 12: 696-703

Hughes M, Forauer AR, Lindh M et al.
Conformation of adjacent self-expanding stents : a cross sectional
in vitro study.
Cardiovasc Intervent Radiol 2006; 29: 255-259



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Sharafuddin MJ, Hoballah JJ,
Kresowiki TF, et al.
Long-term outcome following stent
reconstruction of the aortic
bifurcation and the role of
geometric determinants.
Ann Vasc Surg 2008; 22:346-357
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Greiner A, Mhlthaler H, Neuhauser et al.
Does stent overlap influence patency rate of aortoiliac kissing stents?
J Endovasc Ther 2005; 12: 696-703
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Greiner A, Mhlthaler H,
Neuhauser et al.
Does stent overlap influence
patency rate of aortoiliac kissing
stents?
Endovasc Ther 2005; 12: 696-703
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Why using covered stents ?
try to prevent
adverse hemodynamic changes
pathological changes

promising results of stent graft use in iliac region

Mwipatayi BP, Thomas S, Wong J et al.
A comparison of covered vs bare expandable stents for the treatment of aortoiliac
occlusive disease (COBEST).
J Vasc Surg 2011,
Sabri SS, Choudhri A, Orgera G, et al.
Outcomes of covered kissing stent placement compared with bare metal stent
placement in the treatment of atherosclerotic occlusive disease at the aortic
bifurcation.
J Vasc Interv Radiol. 2010 Jul;21(7):995-1003. Epub 2010 Jun 11.
Bosiers M, Iyer V, Deloose K, et al.
Flemish Experience using the Advanta V12 stent-graft for the treatment of iliac
occlusive disease.
J of Cardiovascular Surgery, Feb 2007, Vol 48, number 1: 7-12


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Sabri SS, Choudhri A, Orgera G, et al.
Outcomes of covered kissing stent placement compared with bare
metal stent placement in the treatment of atherosclerotic occlusive
disease at the aortic bifurcation.
J Vasc Interv Radiol. 2010 Jul;21(7):995-1003. Epub 2010 Jun 11.
Vascular Clinic ZNA
Sabri SS, Choudhri A, Orgera G, et al.
Outcomes of covered kissing stent placement compared with bare
metal stent placement in the treatment of atherosclerotic occlusive
disease at the aortic bifurcation.
J Vasc Interv Radiol. 2010 Jul;21(7):995-1003. Epub 2010 Jun 11.
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COBEST-trial
Prospective,randomised controled trial
Atrium Advanta V12 (81) <->bare metal stents (78)
TASC II B : +/- same results
TASC II C & D : better patency & clinical outcome
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Why using ePTFE covered balloon
expandable stents?


Complete
coverage of the
lesion is needed
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COBEST-trial
TASCII C&D
TASCII B
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COBEST-trial
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Why using Atriums Advanta V12 covered stent

due to specific characteristics:

low profile
double ePTFE layer
easy and accurate deployment
radial force
Dog-bone type inflation of balloon

diameter adaptiveness
(postdilation to a larger diameter is possible without damaging the
stent structure and ePTFE )
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Adaptiveness
1 stent = 4 different shapes
Atrium Advanta V12 L 12x 61 mm
12mm
20mm
12mm
18mm
16mm
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Difference between kissing stent configuration
&
neo bifurcation with covered stents
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CERAB - technique
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23 patients with aortoiliac occlusive disease
20 patients >6 months follow up

TASC II C (10) and D (13) lesions.

12 patients received endarteriectomy of the femoral
bifurcation to ameliorate distal outflow

Femoral access +/- brachial access

11 patients completely endovasculary (7 & 9 Fr)

Technical success rate was 100%.


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CASE Example
CERAB - technique
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CERAB - technique
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CERAB - technique
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CERAB - technique
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CERAB - technique
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CERAB - technique
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Follow-up 20 ptn (> 6 months)
3 patients died of non-interventional causes

relief of symptoms immediately after revascularisation

by ultrasound (at 1,3,6 and 12 months) / CT-angiography

re-occlusion : 3 patients (at 4,5 & 6 months)
pt 1 : tendency to thrombocytosis,
stop anticoagulation, total occlusion
pt 2 : unilateral ileofemoral stenosis
pt 3 : unilateral stenosis femoral bifurcation

successfully thrombolysis or thrombectomy and treatment of the
outflow problems.


14 patients showed no complications up till now.

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Patient characteristics (20)

Age : 43-75 y <57.5y>
Sex : m : 14 / f : 6
Follow up : 6-35 months

Tabaco : 16 (80%)
Cardiovascular : 14 (70%)
Arterial Hypertension : 15 (75 %)
Chronic renal insufficiency : 2 (10%)
Diabetes : 8 (40%)
Hypercholesterolaemia : 15 (75%)
COLD : 11 (55%)
Radiotherapy : 2 (10%)



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Patient characteristics (20)


Aortoiliac calcifications : 13 (65%)
Distal peripheral arterial disease : 11 (55%)

Previous PTA : 11 (55%)
Stents in iliac region : 6 (30%)
Previous Vascular Surgery : 5 (20%)

Previous CABG : 2 (10 %)
Previous PTCA : 5 (25%)



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Follow-up :

30 day primary patency : 100 %

30 day mortality : 0

30 day morbidity: 2

Ecchymosis groin
Haematoma groin (7 Fr)



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Points
of
ATTENTION


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Potential PROBLEM zones
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Leg occlusion
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Leg occlusion
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Leg occlusion
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Leg occlusion
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Distal disease progression
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In stent stenosis
> 8 months
Advanta V12
Bare stent
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Conclusions

although small number of patients
safe and feasible technique
completely percutaneous ( max access diameter 9 Fr).
Hybrid procedure with i.e. endarteriectomy
more anatomical reconstruction
bifurcated prosthesis, EVAR bifurcation
better hemodynamics ?
short and mid-term results:
encouraging
with evidence of sustained clinical benefit
without signs of accelerated in-stent restenosis.
larger population & longer follow-up is needed
sufficient distal outflow is recommended



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The Future ????
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