K.E.M. Radiology

Video 1 Coronal reconstructed video of infrarenal abdominal aorta with severe atherosclerotic changes and short segment occlusion of the infrarenal segment.

 Interventional technique: 

After adequate pre-procedural patient and relative counselling, an informed consent was obtained. The procedure was performed under monitored anesthesia care. 

Right common femoral arterial access was secured with a 10 F short sheath; a left brachial arterial access was secured with a 4 F short sheath. An aortogram performed via the left brachial access with 4 F pigtail catheter demonstrated a short segment occlusion of the infrarenal abdominal aorta for an approximate length of 25 mm. The proximal landing zone was approximately 10 mm distal to the origin of the renal arteries and the distal landing zone was > 20 mm proximal to the aortic bifurcation. Upsizing of the brachial access was performed with a 6 F,  80 cm long sheath after serial dilatation of the tract (Figure 1, video 2). 

Fig 1 Aortogram via left brachial access demonstrates short segment occlusion of the infrarenal abdominal aorta with multiple collaterals. The aortic bifurcation is well demonstrated with no significant stenosis along both common  iliac arteries. 

Video 2 Digital subtraction angiographic run demonstrating short segment occlusion of infrarenal abdominal aorta. 

The occlusion was negotiated via the left brachial access with a 5 F headhunter catheter and a single length straight tip glide wire. This wire was exchanged for a stiff wire and snared via the right femoral access.  The length of the occlusion was calculated with the 5F sizing pigtail catheter. Pre-dilatation of the occluded segment was performed with a 8 mm x 60 mm 0.035 balloon catheter.  After adequate pre-dilatation, precise placement of the 12 mm x 39 mm balloon mounted stent graft was done across the occluded segment (video 3, video 4, video 5, Figure 2, 3). 

Fig 2 Pre-dilatation of the occluded segment with 8 mm x 60 mm balloon. Note the waist across the occlusion.

Fig 3 Deployment of the 12 mm x 39 mm balloon mounted stent graft across the occlusion. 

Video 3 : Negotiation of occluded segment with straight tip glide wire and 5 Fr Head Hunter catheter. 

Video 4, 5  : The fluoroscopic video demonstrates snaring of the wire that has crossed occluded segment via right femoral access. 

Post stent graft placement balloon plasty was performed to achieve desired luminal gain. Post procedure angiogram showed satisfactory luminal gain with good flow across the stent graft. (Figure 4, video 6)

Fig 4  Aortogram performed post stent graft placement demonstrates good flow across the graft with disappearance of collaterals. The inferior mesenteric artery was successfully spared, with antegrade flow in it. 

Video 6 Post stent graft placement angiography demonstrates adequate luminal gain with flow across the graft and successful sparing of inferior mesenteric artery.  

Discussion:

Management of Infrarenal Aortic Occlusion

Infrarenal aortic occlusion represents an advanced manifestation of aortoiliac occlusive disease (AIOD), most commonly attributed to progressive atherosclerosis. Patients typically present with a spectrum of debilitating symptoms, including severe claudication, rest pain, tissue loss, or acute-on-chronic limb ischemia. Historically, open surgical reconstruction—specifically aortobifemoral bypass—has been regarded as the gold standard, providing durable five-year primary patency rates of approximately 80–90% (7,8). However, this invasive approach carries significant perioperative morbidity and mortality risks, particularly for elderly patients and those with multiple comorbidities.

The Evolution of Endovascular Therapy

With iterative advancements in endovascular techniques, high-resolution imaging, and device technology, minimally invasive approaches have gained widespread acceptance for managing complex AIOD. While the TransAtlantic Inter-Society Consensus (TASC II) guidelines initially recommended open surgery for extensive TASC C and D lesions (9), accumulating evidence demonstrates that endovascular therapy can be performed safely and effectively in selected patients. Even in the presence of extensive lesions, these techniques offer high technical success rates and favorable clinical outcomes.

Technical Challenges and Pre-procedural Planning

A primary technical challenge in the endovascular management of infrarenal aortic occlusion is the successful traversal of the occluded segment while maintaining true lumen access. Procedural success is optimized through the strategic use of:

Hydrophilic guidewires and angled catheters.

Adequate guide support and, where necessary, bidirectional (brachial and femoral) access (10).

Pre-procedural Computed Tomography Angiography (CTA): This is crucial for evaluating lesion length, calcification, proximity to the renal arteries, iliac involvement, and distal runoff—all of which dictate technical feasibility.

Advantages of Stent-Grafts

Stent-graft placement offers several mechanical advantages over balloon angioplasty or bare-metal stenting. Covered stents effectively exclude diseased arterial segments, reduce elastic recoil, and minimize plaque prolapse, thereby lowering the risk of restenosis. The COBEST trial demonstrated superior primary patency rates for covered stents compared to bare-metal stents in complex aortoiliac lesions, particularly TASC C and D (11). These findings support the routine use of covered stents and stent-grafts in extensive occlusive disease.

Clinical Outcomes and Limitations

Contemporary studies report high technical success rates for endovascular treatment of chronic aortic occlusion, frequently exceeding 90%, with favorable early and mid-term patency (12,13). In the present case, recanalization of the occluded infrarenal aorta followed by stent-graft placement resulted in the immediate restoration of antegrade flow and significant symptomatic relief, highlighting the effectiveness of this approach.

Despite these advantages, endovascular treatment has recognized limitations. Potential complications include:

Access-site complications.

Distal embolization.

Stent thrombosis or endoleak.

Furthermore, long-term durability remains a concern, as patency data beyond 5–10 years are limited compared to surgical bypass. Consequently, careful patient selection, precise device sizing, and rigorous post-procedural surveillance—combined with lifelong antiplatelet therapy—are essential for optimizing long-term outcomes (14).

Conclusion: 

Infrarenal aortic occlusion is a complex manifestation of aortoiliac occlusive disease that has traditionally been managed with open surgical reconstruction. However, with advances in endovascular techniques and stent-graft technology, minimally invasive management has emerged as an effective alternative in selected patients. Endovascular recanalization followed by stent-graft placement offers high technical success, rapid restoration of antegrade flow, and significant early clinical improvement, while minimizing perioperative morbidity and hospital stay.

Although long-term patency data are still evolving, available evidence supports favorable short- and mid-term outcomes with endovascular therapy, particularly in patients with high surgical risk or significant comorbidities. Careful patient selection, meticulous procedural planning, and structured post-procedural surveillance are essential to optimize results and ensure durability.

In conclusion, endovascular stent-graft placement represents a safe, effective, and less invasive treatment option for infrarenal aortic occlusion and should be considered a valuable alternative to open surgery in appropriately selected patients and experienced centers.

References

1. Norgren L, Hiatt Wr Fau - Dormandy JA, Dormandy Ja Fau - Nehler MR, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45:S5eS67. 

2. Marrocco-Trischitta MM, Bertoglio L, Tshomba Y, et al. The best treatment of juxtarenal aortic occlusion is and will be open surgery. J Cardiovasc Surg (Torino) 2012;53:307e12. 

3. Chiu KW, Davies RS, Nightingale PG, et al. Review of direct anatomical open surgical management of atherosclerotic aorto-iliac occlusive disease. Eur J Vasc Endovasc Surg 2010;39:460e71. 

4. Pilger E, Decrinis M, Stark G, et al. Thrombolytic treatment and balloon angioplasty in chronic occlusion of the aortic bifurcation. Ann Intern Med 1994;120:40e4. 

5. Diethrich EB. Endovascular techniques for abdominal aortic occlusions. Int Angiol 1993;12:270e80. 

6. Indes JE, Mandawat A, Tuggle CT, et al. Endovascular procedures for aorto-iliac occlusive disease are associated with superior short-term clinical and economic outcomes compared with open surgery in the inpatient population. J Vasc Surg 2010;52:1173e9. 1179 e1.

7. Rutherford RB. Vascular surgery. 7th ed. Philadelphia: Elsevier Saunders; 2010. p. 1475–1505.

8. de Vries SO, Hunink MG. Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-analysis. J Vasc Surg. 1997;26(4):558–569.

9. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG; TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45(Suppl S):S5–S67.

10. Gandini R, Fabiano S, Spano S, et al. Endovascular treatment of chronic infrarenal aortic occlusion: technical considerations and long-term follow-up. J Endovasc Ther. 2013;20(3):396–404

11. Mwipatayi BP, Thomas S, Wong J, et al. Comparison of covered versus bare-metal stents for the treatment of aortoiliac occlusive disease: COBEST trial. J Vasc Surg. 2011;54(6):1561–1570.

12. Leville CD, Kashyap VS, Clair DG, et al. Endovascular management of chronic total occlusions of the infrarenal aorta. J Vasc Surg. 2006;43(2):304–309.

(Reports high technical success and favorable outcomes)

13. Indes JE, Mandawat A, Tuggle CT, Muhs BE, Sosa JA. Endovascular procedures for aortoiliac occlusive disease are associated with lower morbidity and mortality compared with open surgery. J Vasc Surg. 2010;52(6):1581–1588.

14. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases. Eur Heart J. 2018;39(9):763–816.