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Vascular and Interventional Radiology |
1 From the Departments of Diagnostic Radiology (K.S., A.M., J.M., P.H., R.W.G.) and Cardiovascular and Thoracic Surgery (K.C., I.P.), University of Technology of Aachen, Pauwelsstrasse 30, D-52057 Aachen, Germany; and the Department of Diagnostic and Interventional Radiology, Clinic of Ingolstadt, Germany (D.V.). Received June 26, 2001; revision requested August 3; revision received November 16; accepted January 18, 2002. Address correspondence to K.S. (e-mail: schuerm@rad.rwth-aachen.de).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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MATERIALS AND METHODS: From 1987 to 1990, 110 patients (mean age, 57 years) with iliac arterial occlusive disease (Fontaine stage IIa, seven patients; IIb, 95 patients; III, four patients; IV, four patients) underwent implantation of a self-expanding metal stent. Stenoses (n = 66) were treated after failed angioplasty, and occlusions (n = 60) were treated with primary stent placement. Follow-up included angiography and/or color duplex ultrasonography and clinical examination with ankle-brachial index measurement. Patients lost to follow-up were interviewed by using dedicated questionnaires administered by telephone and/or mail. If a patient was deceased, relatives and attending doctors were interviewed.
RESULTS: The fate of 109 of the 110 patients was determined. Overall, 46 patients died: 18 within 5 years, 39 within 10 years, and seven after more than 10 years. The 5- and 10-year survival rates were 83% and 64%, respectively. Cardiovascular disease caused 23 deaths; malignant tumor caused 15. The cause of death remained unknown in five patients. Primary stent patency rates were 66% ± 4.8 (standard error) after 5 years and 46% ± 5.9 after 10 years; secondary patency rates were 79% ± 4.2 after 5 years and 55% ± 6.3 after 10 years (Kaplan-Meier test). Seventeen (16%) patients underwent surgical bypass of the aortoiliac arteries that involved the segment with the stent, 14 because of stent restenosis and three because of stenosis in other iliac arterial segments.
CONCLUSION: The main cause of death in patients with intermittent claudication was cardiac disease. Long-term patency of iliac arterial stents was moderate.
© RSNA, 2002
Index terms: Arteries, peripheral, 98.721 • Arteries, stenosis or obstruction, 98.1268, 98.721 • Arteriosclerosis, 98.721 • Stents and prostheses, 98.1268
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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The purpose of our study was to retrospectively evaluate results in 110 patients who had iliac arterial occlusive disease and were treated with stents before 1991.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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Generally, patients preferred endovascular treatment to surgery because they wanted to avoid the risks of surgery. More than 50% of the patients had an increased risk of undergoing vascular surgery because of comorbidities. All patients gave informed consent before the intervention. Overall, 126 iliac arterial lesions (66 stenoses and 60 occlusions) were treated in 123 legs. All patients with iliac arterial occlusions were treated with primary stent placement. The technique of recanalizing iliac arterial occlusion is described in detail elsewhere (8). In brief, the occluded segment is passed with a 5-F multipurpose catheter and a standard straight 0.0035-inch guide wire with a movable core (Cook Europe, Bjaeverskov, Denmark), preferably via an ipsilateral femoral arterial approach. If ipsilateral passage is not possible, contralateral access is used. The occluded iliac arterial segment is dilated by using an undersized balloon. A stent (Wallstent; Schneider, Boston Scientific, Haan, Germany) is placed that is sized to the original normal diameter of the artery and that covers the entire length of the lesion. Balloon and stent diameters are estimated by using adjacent patent iliac arterial segments or the contralateral iliac artery. According to the manufacturer’s instructions, the diameter of the Wallstent should be about 1–2 mm larger than the arterial lumen. If the stent does not expand sufficiently, additional balloon dilation is performed.
In patients with iliac arterial stenosis, indications for stent placement were residual stenosis of more than 30% despite repeated balloon dilation (60 stenoses) or flow-impairing dissection after PTA (six stenoses).
Lesions involved the common iliac artery in 72 patients, the external iliac artery in 36, and both arteries in 18. Sixteen patients had two separate lesions: 13 had bilateral lesions, and three had lesions on the same side. Fifty-three lesions were located on the right side, and 73 were located on the left side. There was an occlusion of the ipsilateral superficial femoral artery in 33 (27%) legs and a stenosis of more than 70% in 17 (14%) of the 123 legs at the time of the first stent treatment. Only Wallstents were placed. The Wallstent had been clinically approved for primary and secondary placement into the iliac arteries at that time. Wallstent design, physical properties, and deployment techniques have been described in detail elsewhere (1,4). One hundred sixty-seven stents were inserted. Ninety-three lesions were treated with one stent; 31, with two; and four, with three. The mean diameter ± SD of the stents was 9.2 mm ± 1.4, with a range of 7–14 mm. The mean length of the iliac arterial segment covered with stents was 56 mm ± 29, with a range of 30–240 mm.
According to the classification of the Society of Cardiovascular and Interventional Radiology (SCVIR) (9), 10 (8%) lesions were category I, 33 (26%) were category II, 42 (33%) were category III, and 41 (33%) were category IV (Table 1). Seven lesions (three stenoses and four occlusions) were 10 cm (n = 1) or more (n = 6) in length (range, 10–22 cm). One patient who had undergone aortobiiliac bypass surgery 6 years earlier had a severe stenosis at both distal anastomoses that was due to neointimal hyperplasia. These eccentric lesions were classified as SCVIR category II. Another patient had a stenosis of the left common iliac artery as a result of displacement of thrombotic material from the right to the left common iliac artery during recanalization of the right common iliac artery. This stenosis was classified as SCVIR category I.
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The cardiovascular risk factor was nicotine abuse in 106 (96%) patients. Only four (4%) patients had no history of nicotine abuse. Twenty-two (20%) of the 110 patients had diabetes mellitus: 15 had non–insulin dependent diabetes mellitus, and seven had insulin-dependent diabetes mellitus.
The anticoagulation protocol after treatment included administration of 500– 1,000 IU of heparin per hour for at least 24 hours. In 100 patients, heparinization was followed by daily administration of 100 mg of acetylsalicylic acid. Ten patients received warfarin sodium therapy for 6 months in the early stage of the trial.
Until 1992, the follow-up protocol had included intravenous digital subtraction angiography (DSA) and clinical examination with ankle-brachial index (ABI) measurement at 1–3 months, 6 months, 12 months, and each following year. All patients had undergone at least one ABI measurement before discharge. In the first 25 patients, intravenous DSA had also been performed before patient discharge. Intravenous DSA had been performed via venous access with a 16-G catheter (Abbocath; Abbott, Sligo, Ireland) placed in a large cubital or lower arm vein. In 1992, color duplex ultrasonography (US) had been added to the protocol. If the results of intravenous DSA and/or color duplex US were nondiagnostic or if there were contradictory results of imaging and clinical examinations, intraarterial angiography was performed. Intraarterial angiography was also performed in patients who had undergone bilateral iliac arterial stent treatment at different times or endovascular treatment of stent restenosis or who had undergone intraarterial angiography for other reasons, such as diagnostic evaluation or treatment of suspected arterial stenosis in the renal or carotid arteries.
Data regarding periprocedural complications of the interventions were collected from the medical reports of the patients and reviewed (K.S.).
From August 1999 to August 2001, data concerning the clinical course of the patients were collected. Approval and informed consent for review of patient records, files, and images is not required by the institutional review board of the University of Aachen. Patients who had not come to a follow-up examination in the previous 12 months were contacted by mail and/or telephone. All telephone interviews were conducted by two investigators (K.S., A.M.). All patients successfully contacted were invited to a follow-up examination. If a patient had died, relatives and/or the referring doctor(s) were asked to provide information about the clinical course of the patient. If no information at all was obtained, the local registration office was contacted by mail and asked whether the patient was still registered under the address known to us, had moved to another place, or had died. Patients who had moved were contacted at their new address by mail and/or telephone.
Telephone interviews were performed by using dedicated questionnaires that were also sent to each patient, or, in cases of patient death, to a relative and/or the referring and/or family doctor(s). The questionnaire for relatives was a simplified version of the questionnaire for doctors.
The following questions were included: "Did the patient have persistent or recurrent symptoms of claudication?" "Which leg was affected?" "Did the patient have pain at rest?" "What was the minimum walking distance without symptoms of claudication?" "Had follow-up examinations been performed in other institutions (if so, what were the addresses of the institutions)?" "Had the patient undergone vascular surgery (if so, what type of surgery [aortoiliac or aortofemoral arterial bypass, profundoplasty, femoropopliteal arterial bypass, etc ])?"
If a patient had died, the doctor and/or relative was asked to indicate the cause of death (heart attack, stroke, malignant tumor [bronchial, colonic, etc]). If a patient had undergone follow-up examination and/or vascular surgery of the lower extremities elsewhere, that institution was contacted for acquisition of the resultant images and reports. Images and/or reports obtained were included in the evaluation. The reason for surgery, pre- and intraoperative findings, and postoperative clinical status were noted. Images and reports were reviewed by one author (K.S.). DSA images were evaluated for stenosis or occlusion in the iliac arterial segment in which the stent had been placed, and the degree of stenosis was assessed.
Data collected regarding stent patency and patient survival were analyzed by using the Kaplan-Meier method.
Definition of stent restenosis was based primarily on angiographic and/or color duplex US findings and secondarily on ABI measurements and/or clinical information (Fontaine stage). Restenosis was defined as more than 30% diameter reduction inside or at the ends of a stent at angiography and/or a greater than 2.5 peak systolic velocity ratio (10) at color duplex US. When no angiographic or color duplex US findings were available, stent treatment was considered a failure if there was a decrease of more than 0.15 in the maximum posttreatment ABI and/or deterioration of the previously existing Fontaine stage. Primary patency was defined as absence of stent restenosis, without any intervention in the area of the stent or adjacent segments (11). Secondary patency was defined as absence of stent restenosis after a single percutaneous reintervention in the area of the stent or adjacent segments.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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Cardiovascular causes of death were acute myocardial infarction (n = 10), acute cardiac and circulatory arrest of unspecified origin (n = 4), chronic cardiac insufficiency (n = 2), cardiac insufficiency in combination with acquired respiratory distress syndrome after aortoiliac arterial bypass surgery (n = 1), acute ventricular fibrillation (n = 1), stroke (n = 1), mesenteric ischemia (n = 1), rupture of an abdominal aortic aneurysm (n = 1), bleeding after renal arterial surgery (n = 1), and massive pulmonary embolism (n = 1).
Malignant tumors leading to death were bronchial cancer (n = 8); non-Hodgkin lymphoma (n = 2); esophageal (n = 1), gastric (n = 1), laryngeal (n = 1), and urothelial (n = 1) cancer, and glioblastoma (n = 1).
Follow-up and Stent Patency
Overall, the results of 878 follow-up examinations were available. The average number of follow-up examinations per patient was 8.0 ± 4.6 (range, 1–24). Only 5.1% (n = 45) of the examinations were not performed at our institution. For three of these 45 examinations, not only the report but also the DSA images were available. Images showed a patent stent in one case and a restenosis in two. Follow-up examinations included ABI measurement and DSA in 64% (560 of 878 examinations); ABI measurement only in 14% (124 of 878 examinations); DSA only in 10% (84 of 878 examinations); ABI measurement, color duplex US, and DSA in 6% (50 of 878 examinations); ABI measurement and color duplex US in 3% (29 of 878 examinations); color duplex US only in 3% (25 of 878 examinations); and DSA and color duplex US in 1% (six of 878 examinations). The low proportion of color duplex US examinations is explained by the late and limited availability of this tool. Color duplex US was preferably performed in patients with poor peripheral venous status. Reasons for the combination of color duplex US and DSA are twofold: DSA was performed if the result of color duplex US was ambiguous. In the beginning, our experience with color duplex US was limited, and results were validated with DSA. One hundred five (15%) of the 700 angiographic examinations performed were intraarterial.
All but four patients underwent at least one follow-up angiographic or color duplex US examination; these four patients were followed up only clinically. A female patient with compensated cardiac insufficiency who lived about 500 km from our institution was followed up by her family doctor, who informed us of her clinical course. In addition, in the same patient, we obtained a report (including ABI measurement) on rehabilitation treatment at a specialized cardiovascular center 3 months after stent treatment. Reports demonstrated that the patient’s clinical status remained stable. Two other patients who underwent only clinical follow-up examinations, including ABI measurement, were examined at our institution: One declined treatment with intravenous DSA for cardiac reasons, and the other had poor peripheral veins. The clinical result was stable in both patients. The fourth patient, who was followed up at another hospital, had early failure of stent treatment and required lower-leg amputation (see subsequent section, "Surgery"). In a fifth patient, the first angiographic examination after stent treatment was performed only 5 years after stent placement at another hospital when the patient finally decided to undergo vascular surgery. The stent was occluded. In this patient, stent thrombosis had occurred within 24 hours after successful treatment of a left external iliac arterial stenosis. Stent thrombosis was diagnosed clinically because of recurrent deterioration of the ABI, recurrent weakening of the femoral arterial pulse, and unchanged claudication. Thrombosis was likely the result of impaired arterial inflow resulting from persistent severe stenosis of the left common iliac artery that did not respond sufficiently to PTA and could not be passed by using the stent delivery system. Follow-up angiography was not performed because there were no more promising endovascular treatment options. Although there were no or only late results from imaging procedures, the preceding five cases were included in the calculation of the stent patency rate. The latter two were considered early treatment failures, and the former three were considered successes until the time of the final follow-up examination.
Overall, in the patients followed up in the current study, three had early stent treatment failure: one within 24 hours, and two within 30 days. Two of the patients have already been mentioned; the third, who underwent recanalization of an occluded left iliac artery, presented with acute stent thrombosis without an obvious cause 4 weeks later.
Twenty-six (20 at our institution) of the 58 patients who were alive and did not undergo stent-excluding iliac arterial bypass surgery underwent a follow-up examination including color duplex US and/or angiography in the 11th year after iliac stent placement; seven of the 58 patients (two at our institution), in the 10th year; and nine of the 58 patients (six at our institution), in the 9th year. Two patients who had died more than 10 years after stent treatment were already deceased when we tried to contact them for invitation to a follow-up examination. Three patients were in such poor clinical condition that such an examination was not reasonable; two of them died soon after. Nine patients who had undergone the last follow-up examination 0.5–7.7 years after stent placement did not accept the invitation for 10-year follow-up examination and reported no symptoms. We failed to contact two patients (see previous section, "Patient Survival and Causes of Death").
Based on the results of angiography and/or color duplex US in 105 patients and clinical follow-up in the five patients mentioned previously, the primary cumulative stent patency rates according to the Kaplan-Meier method were 66% ± 4.8 after 5 years and 46% ± 5.9 after 10 years; the secondary patency rates were 79% ± 4.2 and 55% ± 6.3 (Fig 2) (Table 2), respectively. The mean follow-up time was 5.68 years (95% CI: 5.00, 6.36; range, 1 day to 11.94 years). Restenosis occurred in 51 (40.5%) of 126 lesions after a mean of 3.91 years (95% CI: 2.96, 4.86; range, 1 day to 11.58 years).
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In category III lesions, the standard error increased to more than 10% after 8 years. The primary cumulative patency rate after 8 years was 62% ± 8.9. The secondary cumulative patency rate after 8 years was 76% ± 8.0.
In category IV lesions, the standard error increased to more than 10% after 10 (primary patency) and 9 (secondary patency) years. The primary cumulative patency rate after 9 and 10 years was 42% ± 9.1. The secondary cumulative patency rate after 9 years was 60% ± 9.3.
Six of the seven lesions 10 cm or longer reoccluded after a mean of 4.06 years (95% CI: 1.11, 7.01; range, 0.80–7.01 years).
The course of the Fontaine stage is demonstrated in Table 4. At the time of discharge, all but two patients with Fontaine stage IIb had improved at least one stage. One of the patients who did not improve had early thrombotic stent reocclusion. The second patient, who underwent stent treatment of a common iliac arterial stenosis, had distal occlusion of the superficial femoral artery and improved from stage IIb to I only after femoropopliteal arterial bypass surgery 14 months later. The stent remained patent during follow-up.
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Repeat Intervention
Repeat percutaneous intervention was performed in 23 of the 51 patients with restenosis (Fig 3). Eight patients underwent iliac arterial bypass surgery. Twenty patients underwent no repeat intervention at all, because a long-lasting or major improvement of symptoms from claudication was no longer expected or the patients preferred conservative treatment.
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Surgery
Evaluation of medical history revealed that four patients had undergone pelvic (n = 2) or femoropopliteal (n = 2) arterial bypass surgery several years before stent treatment. Twenty-eight patients underwent surgery of the aortoiliac and/or femoropopliteal arteries during follow-up. Seventeen of the 28 patients underwent aortoiliac arterial bypass surgery involving the segment that contained the stent(s) a mean of 7.11 years (95% CI: 5.72, 8.50; range, 1.45–10.92 years) after placement of the first stent. Fourteen of the 17 patients had iliac arterial stent stenosis or occlusion at the time of surgery. Three other patients had a patent stent at the time of surgery but had severe stenoses and/or occlusions in other iliac arterial segments on the ipsilateral and/or contralateral side. Only four of the 17 patients underwent surgery at our hospital.
Fifteen patients, two with abdominal aortic aneurysms, underwent aortobiiliac or aortofemoral arterial bypass. One patient underwent right-to-left transverse extraanatomic iliac arterial bypass 18 months after implantation, because of iliac arterial stent occlusion. Earlier, an attempt at percutaneous revascularization had failed. A second patient was treated with aortounifemoral arterial bypass 83 months after implantation, as a result of stent occlusion.
Six patients underwent femoropopliteal bypass surgery on the body side on which the iliac stent was located. One patient with bilateral iliac stents underwent bilateral femoropopliteal bypass surgery.
One patient who had developed forefoot gangrene after occlusion of the left common iliac artery showed clinical improvement after treatment and was referred back to another hospital 24 hours later. The patient required ipsilateral amputation of two toes 3 days after stent treatment and amputation of the lower leg 6 days later because of progressive gangrene. It was supposed that stent thrombosis had occurred. Surgery was performed at the other hospital, and no color duplex US or angiography was performed.
Complications
Acute occlusion of the internal iliac artery during recanalization of an occluded right external iliac artery caused no symptoms in one patient.
Major complications requiring additional percutaneous or surgical intervention and/or extension of hospital stay were encountered in nine (8.2%) patients. Three patients with iliac arterial occlusions underwent embolization of thrombotic material. In the first patient, thrombotic material was displaced from the right to the left common iliac artery during recanalization of the right common iliac artery. The material was fixed to the arterial wall by implanting a stent. In the second patient, crossover embolization of old clot material from the occluded left common iliac artery into the right tibioperoneal trunk required surgical embolectomy. In the third patient, ipsilateral embolization of a small thrombus into a tibial artery near the level of the trifurcation was successfully treated with an additional 5,000-IU bolus of heparin and with prolonged full heparinization for 72 hours.
Four patients had a dissection that extended beyond the originally treated segment and required additional stent placement. In the first patient, an acute dissection after PTA of a stenotic segment near the origin of the left internal iliac arteries extended caudally into the distal external iliac artery and also for a short distance cranially into the common iliac artery. In the second patient, an acute dissection after recanalization of a right common iliac arterial occlusion extended into the external iliac artery. In the other two patients with successful treatment of a left common iliac arterial stenosis, a slowly growing chronic dissection was observed. A small dissection distal to the stent was primarily regarded as irrelevant. Early follow-up examinations showed no change; however, after 5.5 and 10.0 months both patients demonstrated marked stenosis of the external iliac artery that was attributed to distal progression of the dissection.
Stent misplacement occurred in one patient. A stent placed across a short severe stenosis at the origin of the left common iliac artery slipped distally during PTA. A second stent overlapping the first was placed to completely cover the lesion. One patient who developed pneumonia of the right lower lobe of the lung and Staphylococcus aureus septicemia 5 days after stent placement underwent antibiotic drug therapy.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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The overall mortality rates from all causes in patients with intermittent claudication were reported as approximately 30% after 5 years, 50% after 10 years, and 70% after 15 years (14). The mortality rates of 17% after 5 years and 36% after 10 years observed in the current study are lower. This may be explained by the relatively low mean patient age at the time of the first treatment (57 years), and/or the small percentage of patients with critical limb ischemia (Fontaine stage III or IV) (7.3%). The latter have a higher risk of death, particularly as a result of cardiovascular causes. In a published prospective follow-up study of more than 550 patients with critical limb ischemia (15), 21.9% of patients were deceased after 1 year and 31.6% after 2 years. The overall incidence of cardiovascular death was 34.5%, as compared with 8.5% of deaths resulting from nonvascular causes. It may also be hypothesized that successful treatment of claudication prolonged survival time; however, to our knowledge, there are no study findings proving this hypothesis.
To our knowledge, ours is the first study in which 10-year follow-up results of iliac arterial stent placement have been presented. However, some limitations were accepted to make this retrospective study possible. The data presented are in part based on clinical information provided by persons (patients or relatives) with no medical education. A small number of patients who underwent no imaging follow-up were included in the calculation of patency rates. Some patients did not undergo long-term clinical and imaging follow-up at our institution but were followed up at other institutions. Therefore, the standards applied for evaluating and reporting the results of stent treatment are likely to vary to some degree. Moreover, in patients with restenosis, the criteria for making the decision to perform percutaneous repeat intervention or surgery may differ between institutions and specialities. While the interventional radiologist may still see an indication for percutaneous repeat intervention, the vascular surgeon may already favor surgery. This factor, which was presumed to be most important in the beginning of the era of stent treatment, when there were no generally accepted standards or long-term results, probably affected the secondary stent patency rate and data on surgery after stent treatment.
As compared with patency rates in patients treated with aortoiliac bypass surgery, 5- and 10-year patency rates in patients treated with stents in this study are worse. In a meta-analysis of 23 studies on aortoiliac or aortofemoral bypass grafts that were published between 1970 and 1996, De Vries and Hunink (16) calculated limb-based patency rates of 91.0% and 86.8% at 5 and 10 years, respectively, for patients with claudication, and of 87.5% and 81.8% for patients with ischemia.
The better patency rate with conventional bypass surgery is probably based on complete exclusion of the diseased iliac arterial segments, including the distal abdominal aorta. With bypass surgery, restenosis is usually confined to the anastomotic region. However, there is a persistent increase in the risk of graft thrombosis, because of the thrombogenicity of the synthetic graft material that will not completely endothelialize, except for the anastomotic region (17). In contrast, even if both iliac arteries are supported by stents over the entire length, the underlying arterial wall remains unexcluded as a major source for the restenotic process. Restenosis may occur in all iliac arterial segments. On the other hand, the mortality rate of aortoiliac or aortofemoral arterial bypass surgery is still greater than 3%, even in more recent studies, and the morbidity risk is 8.3% (16). Less radical surgical options that may be used for localized iliac occlusive disease, such as femorofemoral or ileofemoral arterial bypass, may have a lower mortality rate (18); however, the rate will still be higher than that with stent treatment, which is near zero. Moreover, local iliac arterial bypass surgery is likely to be less effective, as it inherently enhances the risk of occlusive disease in unexcluded segments. Endovascular placement of stent-grafts may be an alternative to surgery that also results in exclusion of the underlying diseased arterial wall; however, long-term follow-up results are not yet available (19).
The high number of early (within the first 2 years after treatment) restenoses observed with SCVIR category IV lesions, particularly those 10 cm or longer, raises the question of whether PTA and stent placement should be performed in such lesions, provided that bypass surgery is possible without a disproportionately high mortality risk. In a recent review article about options in surgical management of aortoiliac occlusive disease, Rutherford (18) stated that iliac arterial PTA and stent placement should not be extended to category III and IV lesions without demonstrating superior long-term results for such lesions. Our long-term results with category IV lesions may support this statement, but relatively good results with category III lesions do not. The size of the study population is still too small to give any general advice for the best treatment option in category III and IV lesions. For now, decisions should be based on the individual patient until more data on long-term results after iliac arterial stent placement are available.
In summary, our long-term results of iliac arterial stent treatment in patients with arterial occlusive disease show that the percutaneous approach is a relevant option among the many surgical and nonsurgical methods available to treat these patients. Iliac arterial stent placement has a low procedure-related morbidity and mortality rate and a moderate patency rate and should preferably be used in patients with SCVIR category I, II, and III lesions.
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FOOTNOTES |
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Author contributions: Guarantor of integrity of entire study, K.S.; study concepts, K.S., D.V., A.M.; study design, K.S., A.M.; literature research, K.S., P.H.; clinical studies, K.S., A.M.; data acquisition, K.S., A.M., K.C., I.P.; data analysis/interpretation, K.S., D.V.; statistical analysis, K.S., J.M.; manuscript preparation, K.S., P.H.; manuscript definition of intellectual content, K.S., D.V., R.W.G.; manuscript editing, K.S., D.V.; manuscript revision/review, K.S., D.V., R.W.G., J.M.; manuscript final version approval, K.S., D.V., R.W.G., J.M., P.H., K.C., I.P.
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= deaths. Numbers indicate numbers of patients at risk.
