Endovascular intervention is appropriate for the treatment of almost all aorto-iliac peripheral arterial disease lesions, and evidence does not support one type of stent over others, according to new recommendations issued today by the Society for Cardiovascular Angiography and Interventions.
Endovascular intervention is preferred over aorto-iliac bypass for the treatment of Trans-Atlantic Inter-Society Consensus (TASC) lesions A, B and C in aorto-iliac PAD because it has been associated with lower mortality rates, according to the statement. The authors noted that the in-hospital mortality rate is 2.7% for aorto-iliac bypass and lower for endovascular intervention.
“Treating these blockages with open surgery is often a last approach due to the surgical risks and the requirement for an inpatient hospital stay,” consensus statement lead author Andrew J.P. Klein, MD, FACC, FSCAI, director of endovascular services and cardiovascular research at the St. Louis Veterans Administration Health Care System and assistant professor of medicine at St. Louis University School of Medicine, said in a press release. “Endovascular treatment has a success rate of more than 90% and a low mortality rate, making it an appropriate treatment strategy when lifestyle approaches and exercise are no longer effectively controlling symptoms.”
Endovascular intervention can also be considered for many TASC D lesions, the most serious, “in experienced hands,” the authors wrote. “With the development of chronic total occlusion devices, many aorto-iliac occlusions may be recanalized safely by endovascular means.”
“Even with revascularizing TASC C and TASC D lesions, if you have experience with reusing reentry techniques and using various precautions to preclude against complications, you can provide a same-day revascularization procedure even in the most complex of diseases,” Klein told Cardiology Today.
Stents similarly effective
Evidence indicates that no clinically available stents indicated for the treatment of aorto-iliac lesions have been demonstrated superior to other stents, according to the authors. For example, the CRISP trial showed no difference in outcomes between patients treated with the SMART stent (Cordis) and those treated with the WallStent (Boston Scientific).
According to the statement, advantages of balloon-expandable stents for aorto-iliac lesions include more precise placement and good radial strength, which may be advantageous for heavily calcified lesions or those that have greater recoil. Advantages of self-expandable stents include flexibility, ability to conform to variable vessel diameters, and availability in longer lengths, the authors wrote.
The COBEST trial demonstrated that covered stents may be superior to bare-metal stents for the treatment of TASC C and D lesions, but there appears to be no difference between the stents in the treatment of TASC B lesions, the authors wrote.
In general, intervention is appropriate for patients with significant aorto-iliac disease, defined as stenosis >50%, occlusion or an inadequate luminal diameter to facilitate delivery of large access sheath, according to the document.
A number of factors are recommended for consideration when choosing a site for arterial access, including severity of lesion, location of lesion and availability of radial or brachial artery access.
“We are now at the point where we can provide an endovascular option for high-risk surgical patients, and even for patients that would normally be treated surgically, because of the advances in technology,” Klein told Cardiology Today. “We have seen a movement across all operators in interventional cardiology, interventional radiology and vascular surgery to more of an upfront endovascular approach with surgical intervention for endovascular failures, unless surgery needs to be performed at the same time.”
Aspirin, heparin recommended
The statement authors recommended that patients undergoing endovascular intervention for aorto-iliac disease are prescribed aspirin 81 mg to 325 mg daily. They note that dual antiplatelet therapy is not well-studied in this patient population. For intra-procedural anticoagulation, unfractionated heparin is recommended, as it has been used in most clinical studies of these patients. – by Erik Swain
For more information:
Klein AJP. Catheter Cardiovasc Interv. 2014;doi:10.1002/ccd.25505.
Disclosure: Klein reports no relevant financial disclosures. See the full statement for the other authors’ relevant financial disclosures.