Subintimal Angioplasty of Chronic Total Occlusion in Iliac Arteries: A Safe and Durable Option

BACKGROUND:
Aortofemoral bypass has traditionally been the intervention of choice for chronic total occlusions (CTO) of iliac arteries. However, it is associated with significant mortality and morbidity making this procedure prohibitive in high risk patients. In order to reduce procedural risk, subintimal angioplasty (SIA) for femoro-popliteal CTO has been utilized by many, but few have extended this endovascular technique to treating iliac CTOs. We present out experience with 101 successful SIAs in iliac artery CTO.
METHODS:
A retrospective review of consecutive patients with iliac artery CTO treated with subintimal angioplasty from June 2000 to July 2009 was completed. Demographic and risk factor data were obtained, along with procedural data. Primary and secondary patency was determined by Kaplan-Meier survival analysis. Other outcome data such as relief from claudication, wound healing, amputation, and death was also recorded.
RESULTS:
122 patients underwent an attempted SIA of an iliac CTO, with a success rate of 83% (101/122). Technical failure was due to the inability to re-enter the lumen in all cases. Mean age of patients was 65 years (range:42-90), with a male-to-female ratio of 3:2. Clinical profile for this cohort was remarkable for a high percentage of coronary artery disease (58%), diabetes (40%) and end-stage renal disease (13%). 32 (32%) of these patients were considered to be non-surgical candidates. Indications for iliac SIA were severe claudication, 64 (64%), and critical limb ischemia, 37 (36%). 90 patients underwent percutaneous SIA, while 11 patients underwent a hybrid procedure: SIA with an ipsilateral femoral endarterectomy or femoral-to-distal bypass. Lesion distribution was 69 common iliac arteries and 61 external iliac arteries. In 20 patients, a more distal lumen re-entry was achieved into the superficial femoral artery (16) or the popliteal artery (4). In 82 (81%) patients, stents were deployed with an average of 1.1 (range:0-3) stents utilized. True lumen re-entry was achieved with an assist device in 15 (15%) patients. Mean pre-operative ABI was 0.52 (range:0.12-0.95). Mean post-procedural ABI was 0.76 (range:0.36-1.30). Mean ABI at last follow-up was 0.80 (range:0.36-1.20). Claudication improvement was documented in 46 (72%). Primary patency was 80% and 69% at 1 and 2 years respectively. Secondary patency was 92% and 86% at 1 and 2 years respectively. Limb salvage was 99% and 97% at 1 and 2 years respectively. After SIA, 9 out of 12 patients with ulcers healed. Procedural 30-day mortality rate was 1% (1/101); one patient died from an intraoperative rupture of a proximal common iliac aneurysm. Survival rate was 93% and 65% at 1 and 4 years respectively, reflecting the poor health status of this cohort.
CONCLUSIONS:
This study demonstrates that SIA of iliac CTO is feasible and can be performed safely and effectively, even in high risk patients. Excellent patency and limb salvage rates can be achieved. In our experience, the safety and durability of SIA makes it an attractive first-line therapy for iliac occlusive disease.