Kissing Iliac Artery Stent Technique for Salvage of a Total Occlusion of a Jailed Common Iliac Artery

ABSTRACT: A 70-year-old female was admitted to our hospital due to claudication of the left leg. The patient was diagnosed with peripheral artery disease and received endovascular therapy (EVT) with a stent implanted in the right common iliac artery (CIA) at another hospital 3 months earlier. The left CIA was jailed by the stent. We performed EVT for the chronic total occlusion (CTO) of the jailed left CIA. A kissing-stent strategy was selected because the strut could not be fully opened. The wire was crossed through the stent strut, since passing the wire outside of the stent was problematic. A balloon was dilated at the stent strut and further inserted while dilated in order to create a space between the implanted stent and opposite aorta wall. Finally, a wire was successfully crossed outside of the stent in this space. A balloon-expandable stent was implanted at the aorta to left CIA in order to perform the kissing-stent technique. Additionally, a self-expandable stent was deployed at the left external iliac artery. To facilitate kissing-stent technique for a jailed CIA CTO lesion, inserting the balloon while inflated at the bifurcation was useful to create space for advancing the guidewire along the stent.

J INVASIVE CARDIOL 2014;26(3):E29-E31

Key words: kissing-stent technique, pushing balloon

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Endovascular stent implantation is an accepted alternative to conventional surgery for iliac lesions.¹ Moreover, kissing-stent reconstruction of the aortoiliac bifurcation is a widely used technique for the management of aortoiliac occlusive disease.^2,3 However, to date there are no reports involving the kissing-stent technique for salvage of a total occlusion of the jailed common iliac artery.

Case Report. A 70-year-old female with medical history including hypertension and dyslipidemia was admitted to our hospital due to claudication of the left leg. The patient was diagnosed with peripheral artery disease with severe stenosis of the right common iliac artery (CIA) by aortography at another hospital 3 months prior. Endovascular therapy (EVT) for the right CIA with a balloon-expandable stent (8.0 × 27 mm Express LD; Boston Scientific Corporation) was performed. The stent was implanted from distal aorta to right CIA which jailed the left CIA. However, 3 months after the index EVT, the patient complained of claudication of the left leg and was admitted to our hospital. The ankle-brachial index (ABI) was determined to be 0.85/0.52 (right/left), suggesting ischemia of the left leg. Aortography and computed tomography angiography (CTA) demonstrated total occlusion of the distal aorta to the left common iliac artery with severe calcification, with the ostium of the left CIA completely jailed by the implanted stent from the distal aorta to the right CIA (Figures 1 and 2). Although we recommended femoral-femoral bypass, the patient strongly preferred EVT to bypass therapy. EVT was performed for the totally occluded lesion of the left CIA. The patient had been maintained on 100 mg aspirin and 200 mg cilostazol daily after index EVT. An intraarterial bolus of 7000 units of unfractionated heparin was administered prior to EVT, and activated coagulation time was maintained at >200 s during the procedure. A 6 Fr sheath (Terumo Corporation) was inserted into the right femoral artery (FA), and 6.5 Fr sheathless guiding catheter (Medikit Co, Ltd) was inserted into the left FA under contrast due to weak pulsation. Intravascular ultrasound (IVUS) was performed through the implanted stent at the right CIA to confirm the ostium of the left CIA from the right CIA (Figure 3). A 0.018˝ Treasure guidewire (Asahi Intecc) with a MetalTip microcatheter (Asahi Intecc) was advanced in a retrograde approach from the left FA. The wire could not cross the CTO lesion due to a calcified lesion and the guidewire was changed out to a  0.018˝ Astato (Asahi Intecc), which subsequently passed to the descending aorta through the stent strut. IVUS was then performed. The wire passed through the true lumen of the left CIA and the diameter was approximately 8.5 mm. However, it was understood that the stent strut of the previously implanted Express LD jailing the ostium of the left CIA couldn’t be expanded greater than 5 mm. Therefore, a strategy to perform the kissing-stent technique to fully dilate a stent implanted from the aorta to the left CIA after crossing the second wire through the outside of the previously implanted right CIA stent (Figure 4) was determined. An attempt to cross the second wire on the outside of the stent failed due to lack of space between the stent struts and the aorta wall. In order to create a space between the implanted stent and aorta wall, a 2.0 mm balloon was placed into the stent strut along the first wire. The balloon was dilated and further inserted while inflated in order to create a space between the stent and aorta wall (Figure 5). The second wire could then pass through the space created (Figure 6). Kissing-balloon dilation was performed using two 5.0 mm balloons. A 7.0 × 37 mm Express LD balloon-expandable stent was deployed from the aorta to the left CIA arranging kissing stent. An 8.0 × 80 mm self-expandable SMART stent (Cordis Corporation) was subsequently deployed at the left CIA. The final angiogram showed successful revascularization at the left CIA CTO lesion and IVUS showed a fully dilated stent (Figure 7). ABI of the left leg improved from 0.52 to 0.86. At 1 year post procedure, the patient was free from claudication and CTA revealed a patent stent (Figure 8). 

Discussion. This report outlines a successful EVT with kissing stent in a patient with intermittent claudication from total occlusion of the jailed left CIA. Aorto-iliac endovascular reconstruction with kissing-stent technique is a safe and effective procedure in aorto-iliac disease.² The long-term durability clinical benefit of aorto-iliac stenting has been studied over the last decade.^3,4 Kubo et al⁵ reported that the secondary patency of an iliac lesion was 99% at 7 years. Therefore, primary stenting is a standard treatment modality for an aorto-iliac occlusive lesion. However, in this case, performing the kissing-stent technique for the total occlusion was problematic due to the jailed stent at the left CIA. To complete kissing stenting for the jailed CIA CTO lesion, inserting a dilated balloon at the stent strut was useful to create a space and advance a guidewire outside of the stent.

Conclusion. This novel technique offers another treatment option for total occlusion of a jailed stent for the CIA. Further experience is needed to confirm the safety of this novel technique.

 References 

1. Henry M, Amor M, Ethevenot G, Henry I, Mentre B, Tzvetanov K. Percutaneous endoluminal treatment of iliac occlusions: long-term follow-up in 105 patients. J Endovasc Surg. 1998;5(3):228-235.
2. Haulon S, Mounier-Véhier C, Gaxotte V, et al. Percutaneous reconstruction of the aortoiliac bifurcation with the kissing stents technique. J Endovasc Ther. 2002;9(3):363-368.
3. Leville CD, Kashyap VS, Clair DJ, et al. Endovascular management of iliac artery occlusions: extending treatment of TransAtlantic Inter-Society Consensus class C and D patients. J Vasc Surg. 2006;43(1):32-39.
4. Soga Y, Iida O, Kawasaki D, et al. Contemporary outcomes after endovascular treatment for aorto-iliac artery disease. Circ J. 2012;76(11):2697-2704. Epub 2012 Aug 2.
5. Kudo T, Chandra FA, et al. Long-term outcomes and predictors of iliac angioplasty with selective stenting. J Vasc Surg. 2005;42(3):466-475.
6. K. Bjorses a, K. Ivancev, et al. Kissing stents in the aortic bifurcation — a valid reconstruction for aorto-iliac occlusive disease. Eur J Vasc Endovasc Surg. 2008;36(4):424-431.

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From the Division of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Japan.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted July 25, 2013, provisional acceptance given August 6, 2013, final version accepted August 8, 2013. 

Address for correspondence: Kenya Nasu, MD, Division of Cardiovascular Medicine, Toyohashi Heart Center, 21-1 Gobudori, Oyama-cho, Toyohashi, 441-8530, Japan. Email: nasu@heart-center.or.jp