Predicting outcome of angioplasty and selective stenting of multisegment iliac artery occlusive disease

Background: Patients who require angioplasty and stenting of multiple iliac arterial segments often require reintervention to maintain long-term paten cy. Morphologic predictors and causes of failure are unknown. The purpose o f the current study was to define arteriographic predictors of angioplasty and selective stent failure in the treatment of multisegment iliac occlusiv e disease. Methods: All iliac segments (two common and two external) of 75 patients wh o underwent angioplasty and selective stent placement for multisegment ilia c occlusive disease (greater than or equal to two segments) were scored thr ough use of a modification of the Society of Cardiovascular and Interventio nal Radiology classification for iliac angioplasty (0 = no lesion; 4 = most severe). Total iliac score was calculated by summing scores from each segm ent. A separate external iliac score was calculated by adding only the exte rnal iliac scores. Arteriograms were reviewed initially and at the time of lesion recurrence and stratified by lesion location and previous interventi on. Results: The area of previous endovascular intervention was the site of rec urrence in 75% of patients. New lesions, presumably a result of progressive atherosclerosis, occurred in. 15% of patients, and lesions occurred in bot h new and previously treated iliac segments in 10% of patients. Only the ex ternal iliac score was an independent predictor of failed endovascular ther apy despite reintervention. For patients with an external iliac score of 2 or less, the endovascular primary-assisted patency rates at 6, 12, and 24 m onths were 96%, 92%, and 89%, respectively. This was improved in comparison with the 90%, 63%, and 45% patency rates observed in patients with an exte rnal iliac score of 3 or more (P = .001). Patients with an external iliac s core of 3 or more had a significantly lower incidence of hemodynamic and cl inical improvement after intervention and a threefold higher need for surgi cal inflow procedures than patients with an external iliac score of 2 or le ss. Conclusions: Lesion formation after treatment of multisegment iliac occlusi ve disease typically occurs in areas of prior intervention. The extent of e xternal iliac disease can be used to stratify patients with multisegment il iac occlusive disease who will likely respond to endovascular treatment wit h a durable result. Patients with extensive external iliac disease (score g reater than or equal to 3) have poor results after angioplasty and selectiv e stenting as applied in this study, even with endovascular reintervention. They are ideal subjects for prospective comparative studies of competing i nitial therapies, including stenting, endografting, and aortobifemoral bypa ss grafting.