Teaching Case

Male claudicant with an occlusion of the right common iliac artery for more than 3 years.

The patient was referred to our clinic with intermittent claudication in March 1990. Cardiovascular risk factors were smoking and hypercholesterolemia. Symptoms were pain in the right upper and lower leg after a walking distance of 100 m (Fontaine 2b). The femoral pulse as well as the foot pulses on the right were weaker compared to the opposite side. The right ankle brachial index (ABI) was 0.81, the left one > 1. The diagnosis of an 2.5 cm long occlusion of the right common iliac artery was already made 3 years earlier with angiography (Fig. 1).

On March 8, 1990 percutaneous recanalization was performed via an ipsilateral approach from the groin. The occlusion was passed with a straight guide wire with a movable core and a multipurpose catheter [1]. First, the occluded segment was dilated with a 7-mm balloon. There was a marked residual stenosis after balloon dilatation. A self-expanding stent (Wallstent, Boston Scientific, Haan, Germany), 10 mm in diameter and 35 mm in length, was placed and adapted to the arterial wall by careful dilatation with a 10-mm balloon. Full patency could be restored (Fig. 2). The post interventional anticoagulation protocol included intravenous administration of heparin (1,000 I.U./kg body weight) for 24 hours and acetylsalicylic acid 100 mg/d for life. The patient was discharged from hospital the day after the intervention without symptoms of claudication. The ABI at discharge was 0.91, and rose to > 1 after 6 months. Follow-up examinations were performed after 1 and 6 months, and once per year thereafter. Follow-up included intravenous digital subtraction angiography via an transcubital venous access (Fig. 3), ABI measurements and clinical examination; since 1993 color duplex ultrasound was added to the protocol. At the latest control examination in March 2001 the stent in the common iliac artery was still patent, and the patient had no claudication. Color duplex ultrasound showed a slight increase in the peak systolic velocity inside the stent, however, the doppler signal was triphasic (Fig. 4a). A normal triphasic signal was also detetected in the common femoral artery on the right side (Fig. 4b). Iliac artery stent placement has become an established tool in the treatment of peripheral arterial occlusive disease. Early reports on larger series of claudicants treated with iliac artery stent placement date back to 1987/1988 [2,3]. Five-year primary and secondary patency rates of iliac occlusions after percutaneous stent therapy were reported to be 54% and 75%, respectively [4]. Ten-year follow-up results are now becoming available in increasing numbers. This patient supported the good long-term clinical outcome and his 10-year survival after stent treatment by early cessation of smoking (in 1985) [5] and effective medical treatment of the hypercholesterolemia (since 1990).