Percutaneous treatment of complete common iliac artery occlusion by primary stenting

Clinical History

Complete occlusion of the right common iliac artery

Imaging Findings

Patient was admitted because of stage IV disease (Fontaine) with non-healing ulcers of his right foot for a period of 1 month. No right femoral pulse was palpable. Besides smoking and diabetes no additional risk factors were present. Angiography revealed a complete occlusion of the right common iliac artery over a distance of about 2.5 cm (Fig.1). Assumed occlusion time was 6 months. In addition complete obstruction of the ipsilateral sfa was present.

Discussion

The pulseless artery was retrogradely punctured just by palpation. No additional means where used to find the arterial lumen. After mechanical passage of the occluded segment from an ipsilateral transfemoral approach by catheter and straight guidewire( Cook Inc. noncoated), a self-expanding nitinol stent (Smart, Cordis) of 9 mm diameter was placed across the occlusion. Its size was adapted to the contralateral common iliac artery using an intergrated calibration system (Multistar TOP, Siemens Inc.). Note incomplete opening of the stent (Fig. 2 a). After dilation (Fig 2 b) with a 7 mm balloon, the stent is nearly completely expanded. Maximum dilation was avoided not to provoke distal embolization of the occlusion material. Final angiogram shows restoration of the iliac lumen (Fig. 3). The patient was changed into stage II a with the ulcer healing within 3 weeks after treatment. Stents in iliac artery stenosis are not generally primarily indicated since a Dutch multicenter trial did not find a significantly better outcome of primary stenting versus primary PTA. This trial predominantly included iliac stenoses. A different story is treatment of iliac occlusions. In our experience, primary stent placement is a feasible strategy to treat complete iliac occlusions. Stents remodel the arterial lumen instantaneously and limit complications of embolization of occluding material. There are two ways to place a stent: one is mild predilation with a smaller balloon to create a working channel and to test the lesion for its rigidity. The other way is to place a stent primarily without predilation to avoid potential embolization risks from predilation. This technique, however, bears potential problems of safe retrieval of the delivery system or introduction of balloons into the stent if insufficient opening of the stent occurs. In case a Wallstent is used predilation is recommendable because change of length is more predictable in a preexisting lumen, while in an occluded lumen exact prediction of the final stent length after dilation could be become difficult. Full dilation in that particular case was omitted since the occlusion was assumed to be rather fresh. Embolization risk seemed more likely therefore; furthermore the self expanding force of the stent used will continue to open the lumen after placement.

Differential Diagnosis List

Final Diagnosis

Percutaneous recanalization of a complete common iliac occlusion by stenting

URL:	https://www.eurorad.org/case/482
DOI:	10.1594/EURORAD/CASE.482
ISSN:	1563-4086