Abstract
Purpose: To assess the feasibility and efficacy of directional atherectomy in the treatment of iliac stent stenosis or occlusion and to evaluate the histologic composition of excised atherectomy specimens.
Methods: Directional atherectomy of six occluded and 10 severely stenosed iliac stents was undertaken in 12 patients at a mean interval of 28 months (range 3–69 months) after stent insertion for occlusive aortoiliac disease. In cases of stent occlusion, atherectomy was preceded by low-dose thrombolysis. In all patients stent clearance with return of femoral pulses was achieved within 24 hr and there were no significant complications. All excised specimens were sent for histologic examination.
Results: Eleven patients (92%) remain symptom free with unlimited walking distance at a mean follow-up interval of 11.5 months (range 3–31 months) after treatment. Histologic examination revealed typical myointimal hyperplasia at three excision sites, intimal fibrosis at three sites, atheroma at four sites and organized thrombus at six sites.
Conclusion: Atherectomy offers an effective treatment in iliac stent occlusion and restenosis with no significant adverse effects. Debulking of these lesions seems to offer a more logical approach than simple balloon angioplasty. Clinical and duplex follow-up confirms satisfactory outcome within the first year but longer-term results are not yet known. The histologic data obtained demonstrate that stent restenosis and occlusion are likely to be multifactorial, and challenge the assumption that myointimal hyperplasia is the sole cause of iliac stent occlusion.
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Palmaz JC, Richter GM, Noeledge G, Schatz RA, Robison PD, Gardiner GA, Becker GJ, McLean GK, Denny DF, Lammer J, Paolini RM, Rees CR, Alvarado R, Heiss WH, Root HD, Rogers W (1988) Intraluminal stents in atherosclerotic iliac artery stenosis: Preliminary report of a multicenter study. Radiology 168:727–731
Sigwart U, Puel J, Mitkovitch V, Joffre F, Kappenberger L (1987) Intravascular stents to prevent occlusion and restenosis after transluminal angioplasty. N Engl J Med 316:701–706
Dyet JF, Gaines PA, Nicholson AA, Cleveland T, Cook AM, Wilkinson AR, Galloway JMD, Beard J (1997) Treatment of chronic iliac artery occlusions by means of percutaneous endovascular stent placement. J Vase Interv Radiol 8:349–353
Sapoval MR, Chatellier G, Long AL, Rovani C, Pagny J, Raynaud AC, Beyssen BM, Gaux J (1996) Self-expandable stents for the treatment of iliac artery obstructive lesions: Long-term success and prognostic factors. AJR 166:1173–1179
Vorwerk D, Guenther RW, Schumann K, Wendt G, Peters I (1995) Primary stent placement for chronic iliac artery occlusions: Follow-up results in 103 patients. Radiology 194:745–749
Murphy TP, Webb MS, Lambiase RE, Haas RA, Dorfman GS, Carney WI, Morin CJ (1996) Percutaneous revascularization of complex iliac artery stenoses and occlusions with use of Wallstents: Three-year experience. J Vase Interv Radiol 7:21–27
Richter GM, Nöldge G, Roeren T, Brado M, Allenberg JR, Kauffmann GW (1995) Further analysis of a randomised trial comparing primary iliac stenting and PTA. In: Lierman DD (ed) Stents: State of the Art and Future Developments. Polyscience Publications, Canada, pp 30–35
Long AL, Page PE, Raynaud AC, Beyssen BM, Fiessinger JN, Ducimetiere P, Relland JY, Gaux JC (1991) Percutaneous iliac artery stent: Angiographic long-term follow-up. Radiology 180:771–778
Vorwerk D, Guenther RW (1990) Removal of intimai hyperplasia in vascular endoprostheses by atherectomy and balloon dilatation. AJR 154:617–619
Sapoval MR, Long AL, Pagny J, Beyssen BM, Raynaud AC, Rostagno R, Gaux J (1996) Outcome of percutaneous interventions in iliac artery stents. Radiology 198:481–486
Vorwerk D, Guenther RW, Schumann K, Wendt G (1995) Late reobstruction in arterial iliac stents: Percutaneous treatment. Radiology 197:479–483
Kearney M, Pieczek A, Haley L, Losordo DW, Andres V, Scainfeld R, Rosenfield K, Isner JM (1997) Histopathology of in-stent restenosis in patients with peripheral artery disease. Circulation 95:1998–2002
Palmaz JC (1993) Intravascular stents: Tissue-stent interactions and design considerations. AJR 160:613–618
Strauss BH, Umans VA, van Suylen R, de Feyter PJ, Marco J, Robertson GC, Renkin J, Heyndrickx G, Vuzevski VD, Rosman FT, Serruys PW (1992) Directional atherectomy for treatment of restenosis within coronary stents: Clinical, angiographic and histologic results. J Am Coll Cardiol 20:1465–1473
Stemerman MB, Spaet TH, Pitlick F, Cintron J, Lejnieks I, Tiell ML (1977) Intimal healing. Am J Pathol 87:125–137
Vorwerk D, Redha F, Neuerburg J, Clerc C, Gunther RW (1994) Neointima formation following arterial placement of stents of different radial force: Experimental results. Cardiovasc Intervent Radiol 17: 27–32
Schurmann K, Vorwerk D, Kulisch A, Stroehmer-Kulisch E, Biesterfeld S, Stopinski T, Gunther RW (1996) Neointimal hyperplasia in low-profile nitinol stents, Palmaz stents and Wallstents: A comparative experimental study. Cardiovasc Intervent Radiol 19:248–254
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Ettles, D.F., MacDonald, A.W., Burgess, P.A. et al. Directional atherectomy in iliac stent failure: Clinical technique and histopathologic correlation. Cardiovasc Intervent Radiol 21, 475–480 (1998). https://doi.org/10.1007/s002709900307
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DOI: https://doi.org/10.1007/s002709900307