What is the recommended treatment approach for stenting of peripheral arterial dissection?

Stenting for Peripheral Arterial Dissection Management

Provisional stent placement is indicated for peripheral arterial dissection as salvage therapy for flow-limiting dissections or suboptimal results from balloon angioplasty, particularly in iliac arteries. 1

Indications for Stenting in Arterial Dissection

Arterial dissection is a known complication of peripheral vascular interventions that requires prompt management to prevent adverse outcomes. The approach to stenting depends on the anatomical location and severity of the dissection:

Iliac Artery Dissections

• Flow-limiting dissections: Require immediate stenting as salvage therapy 1
• Persistent translesional gradient: Indication for stent placement 1
• Residual diameter stenosis >50%: Indication for stent placement 1

Femoral-Popliteal Artery Dissections

• Stenting should be used primarily as salvage therapy, not as primary treatment 1
• Primary stent placement is not recommended in femoral, popliteal, or tibial arteries unless as salvage therapy 1

Infrapopliteal Artery Dissections

• The effectiveness of stents for infrapopliteal lesions is not well established except as salvage therapy for dissections 1

Management Algorithm for Peripheral Arterial Dissection

1. Assess dissection severity:

   • Determine if the dissection is flow-limiting
   • Measure translesional pressure gradient
   • Evaluate residual stenosis percentage

2. Location-based approach:

   • Iliac arteries:

     • Common iliac artery: Primary stenting is effective 1, 2
     • External iliac artery: Stenting is effective as primary therapy 1

   • Femoral-popliteal arteries:

     • Use stenting only for salvage therapy of suboptimal balloon angioplasty results 1
     • Consider lesion classification (TASC type) when determining approach 1

   • Infrapopliteal arteries:

     • Reserve stenting only for salvage of failed balloon angioplasty 1

3. Technical considerations:

   • Ensure adequate vessel sizing
   • Consider lesion length and complexity
   • Evaluate runoff status (poor runoff is a strong prognostic factor for stenting failure) 1

Clinical Evidence and Outcomes

Arterial dissection during peripheral interventions is associated with decreased primary patency and increased need for reintervention. Recent data shows:

• Incidence of arterial dissection has increased from 2.4% to 3.6% in recent years 3
• Endovascular therapy (primarily stenting) is used to treat 83.7% of arterial dissections 3
• Patients with arterial dissection have significantly lower primary patency rates (86.9% vs 91% at 1 year) 3
• Women are more likely to experience arterial dissection during interventions (47.4% vs 39.7%) 3
• Femoropopliteal segment is most commonly affected by dissection 3

Special Considerations

Risk Factors for Dissection

• Female gender 3
• History of smoking 3
• Complex lesions (longer occlusions, higher TASC grade) 3
• Multiple lesions 3

Pitfalls to Avoid

• Do not stent without hemodynamic assessment: Endovascular intervention is not indicated if there is no significant pressure gradient across a stenosis despite flow augmentation with vasodilators 1
• Avoid prophylactic stenting: Endovascular intervention is not indicated as prophylactic therapy in asymptomatic patients 1
• Consider patient age: Younger patients (<50 years) may have poorer outcomes with surgical interventions, requiring more subsequent interventions 1

Post-Stenting Management

• Antiplatelet therapy is essential after stenting, though specific regimens for dissection management are not well defined 1
• Regular follow-up to assess patency and clinical improvement
• Monitor for restenosis, particularly in high-risk patients

Conclusion

When managing peripheral arterial dissection, the anatomical location guides the approach to stenting. While stenting is effective as primary therapy for iliac artery lesions, it should be reserved as salvage therapy for femoral-popliteal and infrapopliteal dissections. The decision to stent should be based on hemodynamic significance, with careful consideration of patient factors that may affect outcomes.