Late complication of aortoiliac stent placement- atheroembolization of the lower extremities

Abstract

Background: Atheroembolization following aortoiliac stent placement is uncommon. The purpose of this study was to examine the management and risk factors of lower extremity atheroembolization following aortoiliac stent placement for occlusive disease.

Materials and methods: From March 1993 to February 2001, the hospital records of all patients who developed thromboembolic events following aortoiliac stent placement were reviewed. Risk factor analysis was performed by comparing with the control group, which consisted of 493 patients treated with aortoiliac stents during the study period who did not develop atheroembolic complications. Patients with cardiac etiologies or aortic aneurysms as the source of embolization as well as those who developed acute embolization following stent deployment (<30 days) were excluded.

Results: Atheroembolization occurred in eight patients (12 iliac artery stents and 1 aortic stent) at intervals ranging from 9 to 43 months (mean 22 months) following aortoiliac stent placement. Arteriography in all patients implicated the stented artery as the source of atheroembolism. Five corrective operations (two aorto-bifemoral bypasses, one ileofemoral bypass, and two aortoiliac endarterectomies) along with two concomitant femoropopliteal thrombectomies were performed successfully in five patients. The remaining three patients were treated with either thrombolysis and/or additional stent placement, which resulted in either iliac occlusion or recurrent embolic symptoms (P < 0.05). All 3 patients subsequently underwent bypass procedures (one ileofemoral and two femorofemoral bypasses). There was no perioperative mortality. During a mean follow-up of 16 months (range 3 to 45 months), two patients required minor amputations, whereas one required major leg amputation. No further episodes of atheroembolism occurred in the involved limbs following surgical bypass procedures. Risk factor analysis failed to identify potential variables that correlated with atheroembolism following aortoiliac stent placement.

Conclusion: Patients with atheromatous embolization following aortoiliac stent placement should be evaluated aggressively. The treatment of choice is surgical correction or bypass with exclusion of the offending embolic source. Although intra-arterial stent placement in the atheroembolic stented iliac artery is feasible, it may provide a less durable result.