Intervention for Iliac occlusive disease

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Intervention for Iliac occlusive disease
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Iliac PTAS

• BIAS III our index audit procedure
• TASC II accepted for I/C and CLI

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Iliac PTAS Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are the right drugs
• Patent arteries are better than occluded arteries

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Iliac PTAS Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are the right drugs
• Patent arteries are better than occluded arteries

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Dutch Iliac Stent Trial

• Tetteroo, Lancet 1998 3511153-9
• 279 patients
• Primary stent vs PTA bail out stent (43)

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5-8 yr follow-up (Radiology 2006)

• Routine stenting has no advantage over selective
  stenting.
• Better symptom relief with selective stenting
• (HR 0.8 95 CL 0.6 1.0)
• A chance finding?
• Other outcomes no difference

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Interpretation

• Stent use should be restricted to poor PTA
  outcomes
• BSIR III 55 of lesions are stented

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Iliac PTAS Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are the right drugs
• Patent arteries are better than occluded arteries

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• The management of severe aortoiliac occlusive
  disease endovascular therapy rivals open
  reconstruction.
• Kashyap JVS 2008 481451
• Cleveland Clinic

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• Iliac occlusions stenting or crossover grafting?
  An examination of patency and cost.
• Whatling EJVES 2000
• Reading
• Prospective

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PTAS vs Surgery

• Patency inferior
• Cost advantage not proven
• Depends on patency
• UK data needs updating

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Iliac PTAS Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are the right drugs
• Patent arteries are better than occluded arteries

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Aspirin and Statins are good

• Aspirin
• Single RCT shows benefit in PVD patients
• 366 patients
• Reduced risk of CV Death, MI, Stroke
• No difference in leg outcomes

• CLIPS study. J Intern Med 2007 261276

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CAPRIE study systemic benefit
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Maintaining patency after ILIAC PTAS

• Aspirin
• No evidence at all
• Clopidogrel
• Coronary data only
• Cilostazol
• Good data from fem-pop studies
• Why do we ignore it?

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Cilostazol

• cAMP phosphodiesterase inhibitor
• Antiplatelet activity and vasodilator
• Improves walking distance in claudicants
• Reduces restenosis rate in coronary stents
• Reduces restenosis after fem-pop pta

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Cilostazol vs ticlodipine post EVT

• Iida O. Hyogo, Japan
• J Vasc Surg e-pub May 2008
• Randomised trial
• Cilostazol vs ticlopidine (aspirin)
• 127 patients (fem-pop ptas)
• Intention to treat analysis

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Results
P0.013
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Cilostazol vs ticlodipine post EVT

• Significant difference in
• Freedom from revascularisation p0.036
• Freedom from adverse events p0.031
• Restenosis
• Amputation
• Death

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Cilostazol post peripheral EVT

• Soga et al J Am Coll Cardiol 2009 5348-53
• Open label multi-centre RCT
• 80 patients (fem-pop PTAS)
• Cilostazol ASA vs ASA alone

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Cilostazol post peripheral EVT

• Soga et al J Am Coll Cardiol 2009 5348-53
• Freedom from TVR 84.6 vs 62.2
• Binary restenosis rate 43.6 vs 70.3
• No bleeding complications in either grp
• Plt0.05

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Cilostazol post EVT in HD patients

• Ishii et al. Clin J Am Soc Nephrol. 2008
  31034-40.
• 193 Consecutive (non-randomised) cases
• Cilostazol in 71 pts, 130 lesions
• Kaplan-Meier 5-yr patency 52 vs 33

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Cost of dual anti-platelet Rx

• Clopidogrel GBP 37.83 per 30 days
• Cilostazol GBP 35.31 per 28 days

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Statins

• Cochrane 2007
• Statins
• Improve walking distance in PAD
• Reduce cardiovascular events

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Statins

• AN KeelingMJ Lee
• JVIR 2009 201133
• Should incidental asymptomatic angiographic
  stenoses and occlusions be treated in patients
  with peripheral arterial disease?

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Statins

• AN KeelingMJ Lee
• JVIR 2009 201133
• Identify predictors of clinical deterioration
  in asymptomatic lesions in the lower limb

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Predicting deterioration

• 122 patients with asymptomatic disease
• Iliac 11, femoropopliteal 111
• 4.2 yr f/u
• 33 developed symptoms
• Risk factors for deterioration
• Contralateral amputation
• Statin treatment (HR 3.56, CI 1.56-8.13 p.003)!!!

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Iliac PTAS Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are the right drugs
• Patent arteries are better than occluded arteries

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Proximal large vessel occlusion protects the
distal vessels

• Wijendra EJVES 2003
• Unilateral iliac occlusion
• Fem-pop occlusion is less likely
• Park EJVES 2008
• Unilateral iliac occlusion
• Lower run-off resistance score

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Proximal large vessel occlusion protects the
distal vessels

• Wijendra EJVES 2003
• Repeat angios (median 2.1yr interval)
• 200 cases
• 52 limbs with untreated iliac or femoral
  occlusion
• Disease progression does not occur distal to an
  occlusion
• Except lengthening of the occlusion

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• Isolated iliac occlusion claudication
• Multilevel (esp. distal disease) CLI

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Intervention in proximal occlusion

• Distal embolisation
• Inflammatory response
• Prothrombotic cytokines/platelet activation
• Distal disease progression
• Reocclusion in 25
• Stable claudicant becomes threatened limb

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Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are the right drugs
• Patent arteries are better than occluded arteries

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Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are good
• Patent arteries are better than occluded arteries

No level 1 evidence to support this!
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Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are the right drugs
• Patent arteries are better than occluded arteries

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Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are good
• Patent arteries are better than occluded arteries

Not supported by large UK series. Primary patency
of surgery is better
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Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are the right drugs
• Patent arteries are better than occluded arteries

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Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are good
• Patent arteries are better than occluded arteries

No evidence for benefit post intervention The
best evidence favours cilostazol
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Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are the right drugs
• Patent arteries are better than occluded arteries

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Assumptions

• Stents are more effective than balloons
• PTA/S is safer and cheaper than surgery
• Aspirin and statins are good
• Patent arteries are better than occluded arteries

OK but a chronic iliac occlusion is safe and
stable
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