Role of intravascular ultrasound for the technical assessment of endovascular reconstruction of the aortic bifurcation

Objectives: to evaluate the role of intravascular ultrasound (IVUS) for the technical assessment of kissing stents (KS) and covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac obstructive disease involving the aortic bifurcation. Methods: We conducted a single-center retrospective review of patients undergoing endovascular treatment of severe aorto-iliac obstructive disease (2019-2023). IVUS was performed in patients treated by KS or CERAB according to preoperative indications, in cases of moderate/severe calcifications, mural thrombus, total occlusions, and lesion extension towards the proximity of renal or hypogastric arteries. Indications for IVUS-guided intraoperative revisions were residual stenosis or compression >30%, incomplete stent-to-wall apposition, or flow-limiting dissection at the landing site. Follow-up assessment was performed at 6, 12 months, and then yearly. Thirty-days outcomes and two-year patency rates were evaluated. Logistic regression was used to identify factors associated with significant technical defects detected by IVUS needing intraoperative revision. Results: IVUS was used for the technical assessment of 102 patients treated by KS (n=57, 56%) or CERAB (n=45, 44%) presenting with severe intermittent claudication (39%), rest pain (39%), or ischemic tissue loss (25%). Twenty-nine significant technical defects were identified by IVUS in 25 patients (25%) who then had successful intraoperative correction by additional ballooning (n=23, 80%) or stenting (n=6, 20%). Patients with a severely calcified chronic total occlusion (OR 1.85, 95%CI 1.01-5.27; P=.044) or severely calcified narrow aortic bifurcation with <12 mm diameter (OR 2.34, 95%CI 1.10-8.64; P=.032) were at increased risk for IVUS-guided intraoperative revision. There were no post-operative deaths and no major adverse events. Two-year primary patency was 100%. Conclusions: IVUS was used for the technical assessment of KS/CERAB in a selected cohort of patients with severe aorto-iliac obstructive disease. This allowed the identification and intraoperative correction of a significant technical defect not detected by completion angiogram in 1/4 of patients, achieving optimal two-year results. IVUS assessment of KS/CERAB may be considered especially in patients with a calcified total occlusion or narrow aortic bifurcation.