Case 1
56 Year old gentleman presented to your outpatient clinic with rest pain and dry gangrene in tip of his Hallux .Please review his CTA below
Q1: What are the benefits and limitations of endovascular treatment versus open surgical bypass for this patient in context of the current evidence.
Q:2 Can you compare the TASC II versus novel classification system for AIOD based on this CT angiogram?
Q3: Between POA, bare metal stents and covered stents. Discuss and explain your device selection strategy
Q4:How do patient factors, such as diabetes or frailty, influence your decision to proceed with endovascular versus surgical options?
Q5:What strategies would you use to minimize the risk of restenosis or re-intervention in this patient?
Q1
Endovascular has upper hand than open regarding perioperative morbidities and mortality with providing the same patency rate with limb salvage survival rate , patency duration
Q2 TASC D aorta infra renal with both iliac
Novel
A o 3
C o 2 RL
E 0 RL
F 1 sR / F 0l
Q3
CERAB is better as patency rate higher with prolonged duration
BMS causing flow disturbances resulting in neointimal hyperplasia
Q4 prescence of comorbidites in favor of endovascular as systematic review showing perioperative morbidities more with open
Q5
Pre op preparatio ( life style modification- BMT – control blood sugar , lipid profile )
Op : cFA endarterectomy
Using atherectomy devices or IVL ballon before Stenting
CERAB better than BMS
Post op : life style modification
Best medical therapy ( antiplt- hypolipedemic medications- low dose anticoagulant- ant hypertensive mefications )
A1
This is a case of TASC ll D classification of infrarenal aortoiliac occlusive disease which is better treated by open surgical procedure.
But systemic review shows Endovascular intervention offers a better patency rate90% , early recovery than the open surgery.
Limitations: high cost, expensive tools, and need experience. in some procedures hybrid approach is needed for better inflow of blood, risk of restenosis may happen.
A2
TASC ll D
Novel classification: Ao3
CIA oR2, CIA oL2
EIA oR1, EIA oL1
CFA SR1, CFA oLo
A3
According to the studies, covered stents have shown better efficacy than bare metal stents in primary patency, technical success of the procedure.
A4
Age of patient, diabetes, fraility score will interfere with decision and EV approach will be the better option.
A5
good planning of the case
plan our access either transbrachial with CFA cutdown
do CFA endarterectomy as it shows better patency than endovascular option
accurte sizing of the vessels and stent needed
go with CERAB technique better than kissing stent
use covered stent over bare metal
control of patient risk factors
give the patient clear instruction about importance of best medical treatment
put him in active survillence
-Control risk factors
-Selection of better tools, balloon sizes and types, Stent types and sizes.
-Vessel preparartion
-Hybrid approach maybe needed to increase blood vessel inflow
-BMT
-Follow up by duplex U/S.
A1 this patient has a TASC D so better open surgery
but recent systemic reviews shows 90 % patency rate in endovascular repair in the 1st year if done under experienced hands
especially if the patient has multiple comorbidites
and reintervention can be done using percutanous access
limitaion cost and needs experience
A2 TASC D
novel classification
Ao3
CoR2 CoL2
E R1 E L1
FR1 FL1
A3 covered stent shows better results especially in TASC C and D
we better use CERAB technique than kissing stent as it shows better flow hemodynamics in the 1st one
A4 patients with many comprbidites better start with endo option as surgery increases morbidity
A5 good planning of the case
plan our access either transbrachial with CFA cutdown
do CFA endarterectomy as it shows better patency than endovascular option
accurte sizing of the vessels and stent needed
go with CERAB technique better than kissing stent
use covered stent over baremetal
control of patient risk factors
give the patient clear instruction about imporance of best medical treatment
put him in active survillence
A1
recent studies shows that Enovascular repair for TASC2 D is safe and effective with more than 90% patency @ 1 year when done by experienced hands. Re intervention can also be done percutaneuosly
the limitations is the cost and experience
A2
TASC ll D
Ao3
C2o RL
EI1 RL
F0
A3
Covered stents is better than bare metal stents
A4
Diabetes, cardiac state , age and patient fraility would be in favor for endovascular approach
A5
Good control and Modification of risk factors preop
Good sizing and planning by CT studying
Use of coveredstentsin case of endovascular approach
Q(1):
This is a case of TASC ll D classification of infrarenal aortoiliac occlusive disease which is better treated by open surgical procedure.
Endovascular intervention offers a better patency rate, early recovery than the open surgery.
Limitations: high cost, expensive tools, in some procedures hybrid approach is needed for better inflow of blood, risk of restenosis may happen.
Q(2):
TASC ll D
Novel classification: Ao3
CIA oR2, CIA oL2
EIA oR1, EIA oL1
CFA SR1, CFA oLo
Q(3):
According to the studies, covered stents have shown better efficacy than bare metal stents in primary patency, technical success of the procedure.
Q(4):
Age of patient, diabetes, fraility score will interfere with decision and EV approach will be the better option.
Q(5):
-Control risk factors
-Selection of better tools, balloon sizes and types, Stent types and sizes.
-Vessel preparartion
-Hybrid approach maybe needed to increase blood vessel inflow
-BMT
-Follow up by duplex U/S.
A3:
According to the study Efficacy and Safety of Covered Stents Versus Bare-Metal Stents for Aortoiliac Occlusive Disease: A Systematic Review and Meta-Analysis published in 2024 we conclude that CS are favorable than BMS regarding primary patency in patients with TASC D lesions, TLR, technical success rates, and patient long-term survival.
A4:
Patient age and diabetes status with frail general health will interfere the decision and the EV option would be considered in case of frail general condition uncontrolled DM and older ptn with high risk of complications with surgery
A5:
Careful study of the images with anatomical considerations for the inflow outflow and calcification together with good selection of tools and sizes of stents and balloons
Rt CFA endarterectomy to emphasize the outflow and improve the patency
Vessel preparation
Risk factors modification
BMT with COMPASS drug therapy
Follow up plan for serveillence of stent patency and the need for reintervention
A1:
Benefits of EV are the the same limb salvage rate in comparison with DS revascularization with favorable and better 1ry patency rate in EV specially in case of hybrid surgery CFA endarterectomy
Limitations of EV are cost and experience in this technique with some specific limitations in this case scenario regarding the flush infra renal occlusion along with heavily calcified stenotic lesion in the right CFA that need hybrid surgery and CFA EA
A2:
TASC II D
NOVEL classification
Ao 3
Co R 2/ Co L 2
E o R 1/ E o L 1
F s R 1/ F o L 0
A1.. For this patient CTA shows TASC II D .. which is treated by surgical methods .. but recently open surgery is comparable to Endovascular treatment in patients with TASC II D lesions. And results from systematic review and meta-analysis shows that covered stents in sever AIOD are safe and effective with >90% patency rate ..
Limitations are the cost-effectiveness , the news for high experience in Endovascular treatment to deal with such complex lesions
A2..
TASC II D
Novel system
A2o,
C2or and C2ol
E1r and E1L
F 1r and F0L
A3..
For TASC II D lesions COBEST trial shows that covered stents is superior to bare metal stent in TASC c and d AIOD while they are equivocal in TASC B so covered stents is preferred
A4..
Of course comorbedities and fertility are in favour of endovascular option as it is more simple and con be done under local anesthesia
A5..
I will keep the patient on antipletlet therapy and high dose statine and low dose revaroxiban
I will keep the patient on survillence program
I will advice the patient for risk factors modifications such as good control of DM and HTN
1 it’s a case of CLTI with Aortoiliac occlusive disease
so benefits of endovascular ttt: lower risk of intervention , early recovery , patency is comparable to open
Limitations of endovascular ttt: lower patency rate , expensive tools and not suitable for all difficult lesions
2 TASC II : TASC D
Novel classification: A3o CIA 2o r&l EIA1o CFA 0
3 Covered stents the best choice as it offers patency rate comparable to the open surgical technique
4 For patients with multiple co morbidities and high risk for operation , endovascular intervention will be the suitable choice
5 use covered stent
Risk factors modification
Medical ttt as dual antiplatelet and statin therapy
Follow up for 2 years clinically and by duplex
Q1:
according to the CTA the patient has Aorto-iliac occlusive disease (it is cosidered as TASC D category)
according to TASC 2 consensus it is recommended to go for open surgical intervention
but there is a systematic review of endovascular treatment of extreme AIOD done 2010 concluded that the 2ry patency is comparable to surgical repair
and in 2021 asystematic review of covered stent for treatment of AIOD is safe and effevtive with more than 90 % patency at 1 year
and endovascular in selected patient can be done totally under local anesthesia with low morbidity in comparison to open repair
the limitations of endovascular is the expanse of the tools needed for successful intervention
Q2:
this is TASC D
and the novel i think it is considered A2o C2o E1or F1sl
Q3:
according to this patient covered stent will be my choice with primary patency at 1 year more than 90%
Q4:
it is better with patient like diabetic and fragile to go for endovascular as this patient will have poor outcomes in wound healing and high post operative morbidity and mortality
Q5:
best medical treatment to reduce risk factors of atherosclerosis
and according to last trials recommend use of anti platelet and low dose of revarospire
and good surveillance of the stents to detect early re stenosis and manage