Teaching Case

Recent total occlusion of right common iliac artery

Patient presented with stage IV (Fontaine) of peripheral arterial disease. She underwent an episode of stroke 2 months prior to admission. Previous angiography stated left-sided occlusion of both the common iliac artery and the distal popliteal artery, the latter was fairly collateralized. Although the probable event of iliac occlusion was only about 2 months old indicating a rather fresh occlusion, both surgery (because of general conditions) and thrombolysis (because of stroke) were not considered. The patient was admitted for mechanical recanalization. Clinical history of deteriorated perfusion lasted about 2 months.

After smooth passage of the occluded segment by a straight guidewire and a catheter indicating relatively low grade of organization of the occlusion (Fig. 1) the pathway through the occlusion seems to be eccentric. However, easiness of passage makes a subintimal passage less probable than passing through the thrombotic occlusion. A self-expanding 10 mm nitinol stent (Smart, Cordis Inc) was placed into the occluded segment (Fig. 2a) which opened nearly completely but was dilated upt to 8 mm with an appropriate balloon (Fig. 2b). Predilation was avoided in order not to risk embolization of the occlusion material. Run-off angiography stated absence of peripheral embolization and the intervention was terminated. Treatment of iliac occlusions has become a standard procedure in interventional radiolgy while for many years it was considered as a contraindication to balloon angioplasty. Primary stenting offers a rapid and safe recanalization in order to avoid the major drawbacks of PTA: insufficient luminal gain and embolization of occluding material which was found as a frequent complication of pure balloon angioplasty in eralier publications. There is some discussion what age an occlusion should have before mechanical recanalization is safe. On the other hand, fresh thrombosis can be mechanically fixed by stents so even in recent clots, efficacy of stents might work: however no specific data are available.