Modern Invasive Methods of Diagnostics of Stenotic Lesion in Illiac Arteries Segment

Fractional flow reserve (FFR) is now accepted as the reference standard to indicate whether a stenosis is likely to be responsible for ischemia. It is generally accepted that a stenosis with an ischemic value of FFR is responsible for symptom and a worse outcome and should be revascularized, whereas lesions with a non-ischemic FFR have a more favorable prognosis and can be treated medically. Furthermore, FFR-guided revascularization strategy has been definitely proven to be better than angiography-guided strategy in pivotal landmark studies. A gold standard diagnostic tool to determine the hemodynamic significance of an equivocal iliac artery stenosis is the translesional pressure gradient under hyperemic conditions. The purpose of the work was to study possibility of using FFR and measuring gradient of pressure, depending on degree of stenotic lesion of iliac arteries and define impact of these indicators on treatment tactics of patients with CLI. Material and methods. We enrolled forty patients with multilevel lesions of lower extremity who underwent of peripheral FFR (distal mean pressure divided by proximal mean pressure) or measurement of gradient of pressure before hybrid or endovascular treatment. In the FFR measurement a guide sheath was placed on top of common iliac bifurcation and pressure equalization was performed. After advancing pressure wire distal to iliac lesion papaverin administration was selectively performed to the affected iliac artery. Results and discussion. The first group of patients with stenosis lower 70%, 3 (23%) had gradient more than 10 mm Hg and FFR ˂ 0.8. In the same group patients with stenosis of 70–80%, 3 (27.3%) had less than 10 mm Hg. and FFR ˃ 0.8. In the 2nd group of patients with stenosis lower 70%, 1 (16.7%) patient was diagnosed with FFR ˂ 0.8. In same group stenosis of 70–80%, 2 (22.2%) patients were found with gradient less than 10 mm Hg. and FFR ˃ 0.8. Using additional methods to confirm the degree of stenosis in iliac arteries of the lower extremities, we detected 9 patients (22,5%) with conflicting data of angiography and FFR/gradient of pressure. We changed tactics of surgical treatment for these patients. We did not perform stenting of iliac arteries for 3 (20%) patients in the first group who initially planned hybrid surgery, only femoro-popliteal bypass grafting was performed. Conversely, 3 patients (20%) of the first group were indeed candidates for hybrid intervention, despite they had a visually assessed stenosis of iliac segment less than 70%. In the second group, there were 1 patient (6.7%) who needed stenting of the iliac arteries in addition to the endovascular correction of the arteries of the outflow, and 2 (13.5%) did not require stenting of the arteries, despite the fact that they had stenosis of 70-80%. The obtained data showed us angiography for patients with stenosis of iliac arteries, especially in patients with tandem stenosis and 50–70% stenosis, does not give a complete picture of the degree and significance of stenosis. In these conditions, it is necessary to use additional methods of studying the physiology of circulation in this segment, which will allow adequately assessing the significance of stenosis and making faster recovery of the patient, as well as changing the long-term results of treatment after operations. These results will help to improve the prognosis and treatment of patients with multilevel lesion of lower extremity arteries and CLI.