Physician-Initiated Trial Investigating the BeGraft Peripheral Stent Graft System

Endovascular techniques are well accepted in the treatment of iliac occlusive disease. It is shown that in the iliac artery especially stenoses and short occlusions respond well to percutaneous transluminal angioplasty (PTA) with our without stenting. Although hard data are lacking, with the technical developments and the introduction of new stent types, more complex lesions have been treated with endovascular procedures. Although stents are often used to improve the outcome of PTA, there is no general consensus whether stenting is mandatory for chronic iliac arterial occlusion. The more, if we use stents, it is still unclear if we should implant bare self-expandable stents, bare balloon-expandable stents or covered stents. On one hand, the randomized controlled Dutch Iliac Stenting trial failed in demonstrating superiority of primary stenting over PTA with additional stenting in short lesions. On the other hand, while several papers advocate bare stenting, other trials conclude better results with covered stents.

The Trans-Atlantic Inter-Society Consensus (TASC) working group has published in 2000 their recommendations for the management of peripheral arterial disease. In order to better reflect the developments in technology and techniques, the TASC working group has revised and updated their recommendations in the TASC-II document in 2007.

The treatment recommendations between surgical or percutaneous intervention they propose involve all peripheral arterial beds and are based upon several factors such as availability of expertise in the percutaneous or conventional vascular surgical techniques, the patient's preference and most importantly on the lesion's morphology. TASC classifies all lesions in the different beds into types A to D. In general, endovascular therapy is the treatment of choice for TASC A \& B-lesions and surgery is preferred for good-risk patients with TASC C lesions and all TASC D lesions.

For aorto-iliac lesions, the TASC-II classification is as follows:

Type A lesions

1. Unilateral or bilateral stenoses of the Common Iliac Artery (CIA).
2. Unilateral or bilateral single short (≤3 cm) stenosis of the External Iliac Artery (EIA).

Type B lesions

1. Short (≤3 cm) stenosis of infrarenal aorta.
2. Unilateral CIA occlusion.
3. Single or multiple stenosis totaling 3-10 cm involving the EIA not extending into the Common Femoral Artery (CFA)
4. Unilateral EIA occlusion not involving the origins of Internal Iliac Artery (IIA) or CFA Type C lesions
5. Bilateral CIA occlusions 2. Bilateral EIA stenoses 3-10 cm long not extending into the CFA 3. Unilateral EIA stenosis extending into the CFA 4. Unilateral EIA occlusion that involves the origins of IIA and/or CFA 5. Heavily calcified unilateral EIA occlusion with or without involvement of origins of IIA and/or CFA Type D lesions
6. Infra-renal aortoiliac occlusion
7. Diffuse disease involving the aorta and both iliac arteries requiring treatment
8. Diffuse multiple stenoses involving the unilateral CIA, EIA and CFA
9. Unilateral occlusions of both CIA and EIA
10. Bilateral occlusions of EIA
11. Iliac stenoses in patients with an Abdominal Aortic Aneurysm (AAA) requiring treatment and not amenable to endograft placement or other lesions requiring open aortic or iliac surgery

The TASC working group has based their recommendations on the literature available to date and are generally considered as the guidelines to be followed. Nevertheless it should be stated that it is feasible to treat with good technical success and sustained durability TASC type C and D lesions in an endovascular way.

Recent publications finally start to show the excellent durability of iliac stenting in the daily practice. Park et al, described their long term (up to 10 years) experience in their total cohort of iliac patients (TASC type A-D lesions) and presented impressive primary patency rates of 87%, 83%, 61% and 49% at respectively 3, 5, 7 and 10 years after the index intervention. De Roeck et al. published their results after stenting of different types of iliac occlusions (TASC type B-D), and showed primary patency rates of 94%, 89% and 77% after respectively 1, 3 and 5 years follow up. They could also show that in their cohort of patients with complex aorto-iliac lesions, stent-failures can always be endovascularly rescued. They showed secondary patency rates of 100% after 1 year and 94% after both 3 and 5 years. Bosiers et al. concluded in their BRAVISSIMO trial primary patency rates at 12 months for the TASC A, B, C and D lesions of respectively 94.0%, 96.5%, 91.3% and 90.2%. Leville et al. questioned after the presentation of their outcome with stenting iliac occlusion (primary patency rate of 76% and secondary patency rate of 90% after 3 years), whether the endovascular treatment for iliac occlusive disease should be extended to Type C and D lesions. Leville came to this conclusion as they could not detect any significant differences in outcome for both primary and secondary patency rates stratifying for the TASC classifications. They summarized the treatment of iliac artery occlusion can be accomplished via endovascular means with little morbidity and acceptable patency rates. The COBEST trial demonstrates that covered and bare-metal stents produce similar and acceptable results for TASC B lesions. However, covered stents perform better for TASC C and D lesions than bare stents in longer-term patency and clinical outcome. Sabri et al. concluded that the use of covered balloon-expandable kissing stents for atherosclerotic aortic bifurcation occlusive disease provides superior patency at 2 years as compared with bare metal balloon-expandable stents. Bosiers et al. experienced that the implantation of the Advanta V12 PTFE-covered stent for iliac occlusive disease shows to be safe and feasible with excellent clinical results at 1 year in the investigated patient cohort. The TASC stratification is an important tool in allowing us to assess the extent of lesion morphology, but extensive lesions do not preclude successful endovascular treatment. They continued that the fate of the limb is dictated by the infrainguinal disease that is often present in patients with complex iliac occlusions and therefore believe that endovascular attempts should be exhausted before attempting open surgical repair of iliac occlusions because of the decreased perioperative morbidity and good mid-term durability.