F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.133373.3 Case Report Articles Case Report: Endovascular approach with kissing stent technique in aortoiliac occlusive disease (Leriche syndrome) patient

[version 3; peer review: 2 approved]

 Dakota Iwan Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0001-5360-2759 1 Taofan Taofan Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0001-6363-9010 a 1 Indriani Suci Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-9156-0390 1 Afandy Jonathan Edbert Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-4691-8226 2 Al Jaidi Yislam Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Visualization Writing – Original Draft Preparation Writing – Review & Editing 3 Adiarto Suko Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-2848-0566 1 Sukmawan Renan Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing 1 Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia / National Cardiovascular Center Harapan Kita / University of Indonesia Academic Hospital, Jakarta, Indonesia Assistant of Vascular Division, Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia / National Cardiovascular Center Harapan Kita / University of Indonesia Academic Hospital, Jakarta, Indonesia Cardiology Resident, Departement of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia / National Cardiovascular Center Harapan Kita / University of Indonesia Academic Hospital, Jakarta, Indonesia taofan@pjnhk.go.id

No competing interests were disclosed.

 6 11 2024 2023 12 477 28 10 2024 Copyright: © 2024 Dakota I et al. 2024 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background

Aortoiliac occlusive disease (AIOD) or Leriche syndrome, is a form of peripheral arterial disease involving the infrarenal aorta and iliac arteries. The presentation of AIOD ranges from asymptomatic cases to limb-threatening emergencies. Advances and innovations in endovascular devices have replaced traditional surgical interventions for the management of AIOD. Here we report a case of a 52-year-old man presenting with AIOD managed by endovascular approach using kissing stent technique.

 Case presentation

A 52-year-old man, with history of chronic coronary artery disease, diabetes mellitus type 2, long-standing hypertension, and a significant history of smoking, was admitted to our hospital with symptoms of long-standing bilateral claudication which recently progressed to rest pain. A history of AIOD was previously established. AIOD (TASC II Type D) diagnosis was made by lower extremity duplex ultrasound and CT angiography. The patient underwent urgent percutaneous transluminal angioplasty with kissing stent technique. The patient was discharged 4 days after the procedure without any significant complaints, received best medical therapy.

 Conclusion

Endovascular interventions present excellent alternatives to surgical techniques in the treatment of complex AIOD. Herein we presented an endovascular treatment of AIOD utilizing the kissing stent technique which showed satisfactory outcomes.

 aortoiliac occlusive disease Leriche syndrome TASC D endovascular therapy percutaneous transluminal angioplasty kissing stent The author(s) declared that no grants were involved in supporting this work. Amendments from Version 2

The manuscript has been revised according to reviewer comments. Few highlights including:  - Grammatical correction. - Misused term correction. - Additional references in the discussion. - Removing paragraph discussing the non-technical aspect of the case.

 Introduction

Aortoiliac occlusive disease (AIOD), also known as Leriche syndrome results from a chronic occlusive process of the infrarenal aorta and iliac arteries and is one of the cause of peripheral arterial disease (PAD). Epidemiological studies about PAD including AIOD and infrainguinal artery disease have reported that most patients presented with multistage disease. PAD is rare under the age of 50 years, increasing to about 20% by age 60 years and over 40% by age 85 years. An ankle brachial index (ABI) lower than 0.9 is used to diagnose PAD in clinical practice and epidemiologic studies, to identify both symptomatic and asymptomatic patients. 1 , 2

Risk factors for AIOD include hypertension, hyperglycemia, hyperlipidemia, nicotine use, age, male gender, and family history. AIOD patients generally present with a classic triad of clinical symptoms: (1) claudication of lower extremities, (2) impotence, and (3) weak/absence of femoral pulse. Diagnosis of AIOD is made with CT angiography or conventional angiography. Angiography was used to determine the location of the obstruction, length, collateral circulation, and distal patency. 1 , 3

Advances and innovations in endovascular devices offered promising alternatives over standard surgical approach, including in long and complex lesions. Endovascular treatment in the aortoiliac segment has shown high technical success and lower complication rates compared to standard surgery. It also provides excellent patency, making it a valuable option to be considered for Trans-Atlantic Inter-Society Consensus (TASC) C and D lesions, especially in patients who are poor candidates for surgery. 4 Here we report a 52-year-old man presenting with AIOD or Leriche syndrome and managed by an endovascular approach using a kissing stent technique in the National Cardiovascular Center Harapan Kita, Jakarta, Indonesia.

 Case report

A 52-year-old Javanese man was referred to our hospital with a history of chronic coronary artery disease, type 2 diabetes mellitus, long-standing hypertension, and who was a heavy smoker. Over the past year, the patient experienced long-standing bilateral claudication which recently progressed to rest pain, accompanied by occasional episodes of chest pain, particularly during prolonged walking. Additionally, the patient reported symptoms of erectile dysfunction. The patient had known AOID diagnosed following a failed percutaneous coronary intervention (PCI) attempt. His previous medication was aspilet 80 mg once daily, clopidogrel 75 mg once daily, rivaroxaban 15 mg once daily, bisoprolol 2.5 mg once daily, isosorbide mononitrate 2.5 mg twice a day, candesartan 16 mg once daily, simvastatin 20 mg once daily and novorapid 3×16 IU sub cutaneously before meals.

Physical examination showed blood pressure 160/86 mmHg, HR 68 bpm, RR 18 breaths per minute, temperature 36°C. Normal cardiac, abdominal, and extremity examinations. ECG showed sinus rhythm. Chest radiograph revealed cardiomegaly (65% of cardio thoracic ratio (CTR)) and aorta elongation. Laboratory examination was within normal limits. Lower extremity duplex ultrasound (DUS) suspected significant stenosis of the abdominal aorta at the infra-renal level with high end-diastolic monophasic doppler curve in both external iliac artery and common femoral artery and rounded doppler curve in both popliteal, anterior, and posterior tibial artery, no thrombus in the deep veins in both limbs, and positive arterial flow to distal to both legs. Pletismography examination revealed right ABI was 0.42 and left was 0.35, right toe brachial index (TBI) was 0.45 and left 0.49. Lower extremity CT scan angiography (CTA) showed infrarenal abdominal aortic occlusion from aortic bifurcation, to bilateral common iliac artery and causes suspected thrombus, intermittent atherosclerosis of the abdominal aorta, arterial vasculature of both extremities filled distally, no stenosis or occlusion was seen ( Figure 1).

Pre-procedural CT scan angiography.

The patient was diagnosed with chronic limb threatening ischaemia (TASC II type D lesion) causing bilateral aortic infrarenal–iliaca occlusion (Leriche syndrome). The patient was planned to undergo urgent percutaneous transluminal angioplasty (PTA). He got Enoxaparin 60 mg sub cutaneously twice per day, some additional anti-hypertension therapy, and other previous drugs were continued.

The procedure was done by puncturing access via the right brachial artery with a 6F Radial sheath (Terumo, Japan). A JR 3.5/5F diagnostic catheter (Radifocus™ Optitorque™, Terumo, Japan) with support of 0.035 mm exchange wire (Terumo, Japan) was placed in the abdominal aorta above the suprarenal. The aorta blood pressure measurement was 191/74 (120) mmHg. Initial aortography was done and revealed total occlusion in the abdominal aorta from infrarenal the aortoiliac bifurcation until bilateral common iliac arteries ( Figure 2B). Access puncture was then done via both femoral arteries with a 6F Femoral sheath (Terumo, Japan). Blood pressure measurement was done in the femoral artery, the right femoral artery blood pressure was 87/64 (75) mmHg, and the left femoral artery blood pressure was 89/66 (76) mmHg. A 0.035 mm exchange wire (Terumo, Japan) with support of Rubicon 35 Microcatheter (Boston Scientific, MA, US) was used to penetrate the lesion from the right femoral artery and continued from the left femoral artery. Several pre-dilations with 5.0×120×135 mm balloon (Mustang ®, Boston Scientific, MA, US) were performed for 10 seconds with a pressure of 4 atm on the right and left iliac arteries ( Figure 2C and D). Then, aortography was performed again and showed positive flow on both right and left femoral arteries ( Figure 2E). Insertion of 12×95×100 mm stent graft (Seal ®, S&G Biotech, Korea) from the right femoral artery access and 12×75×80 mm stent graft (Seal ®, S&G Biotech, Korea) from the left femoral artery access were done ( Figure 2F). Dilatation of the stents was performed with a kissing stent technique using a 5.0×120×135 mm balloon (Mustang ®, Boston Scientific, MA, US) from the right femoral artery access and a 6.0×100×135 mm balloon (Mustang ®, Boston Scientific, MA, US) from the left femoral artery access simultaneously with pressure of 8 − 12 atm for 10 seconds ( Figure 2G). Following the intervention abdominal aorta blood pressure was 170 / 79 (114) mmHg, right femoral artery blood pressure was 141/68 (98) mmHg, and left femoral artery blood pressure was 137/77 (102) mmHg ( Figure 2H). The total contrast used was 260 mL iopromide 769 mg/mL, dose area product 418.62 Gy.cm 2, and fluoro time was 24.53 minutes.

Percutaneus transluminal angioplasty procedure.

After the procedure, the patient was observed in the intermediate ward. Lower extremity DUS didn’t find any pseudoaneurysm/AV fistula in the right-left femoral region nor deep vein thrombus in both legs, arterial flow was positive to distal of both legs. Plethysmography results were right ABI 0.8 and left 0.77, right TBI 0.75 and left 0.74. Lower extremity CTA revealed patent stent at bilateral common iliac artery, contrast flow was presence to bilateral femoral artery, bilateral infrapopliteal artreies, until bilateral malleolus region especially left anterior tibial artery and right posterior tibial artery. Other contrast flow was improved compared to pre-PTA ( Figure 3). The patient was discharged 4 days after the procedure without any significant complaints, continued his previous medication, and was educated about smoking cessation.

Post-procedural CT scan angiography. Discussion

Definitive treatment approaches to AIOD have changed in recent years. Inter-Society Consensus for the Management of Peripheral Arterial Disease suggested that AIOD patients with TASC C and D classification are preferred for surgical treatment, but there has been a shift in the recent guidelines by the European Society of Cardiology and of the European Society for Vascular Surgery suggested that endovascular-first strategy may be considered for AIOD for patient with severe comorbidities and if done by an experienced team. 5 , 6 Endovascular therapy is a less invasive treatment option and may reduce morbidity. Patients with extensive AIOD could be treated using endovascular techniques with 86% to 100% of the patients' technical success rates. 7 Another recent study by Dong et al. 8 evaluated uninterrupted patency of the treated lesion until 5 years follow-up of AIOD patient treated with endovascular approach was as high as 91.3% and 100% restored blood flow through the original target lesion. Several available reported endovascular techniques for AIOD treatments including covered endovascular reconstruction of the aortic bifurcation (CERAB), unibody bifurcated endografts, and kissing stent technique showed promising patency outcomes. 9 – 11

Although several studies have analyzed factors that may affect long-term patency after endovascular treatment of AIOD, including stent placement, lesion morphology, and outflow, there is no consensus currently on the risk factors associated with restenosis after endovascular intervention in patients with AIOD. 12 A randomized trial comparing primary versus selective stenting for AIOD showed similar long-term patency in both groups, with lower costs in the selective stenting group. 13 Nevertheless, most studies for extensive aortoiliac lesions preferred primary stenting. The argument for primary stenting was that stenting without predilatation (direct stenting) reduced the risk of not only vessel rupture but also distal embolism. 12 A study by AbuRahma et al. 14 showed that selective stenting was associated with reduced clinical success in long lesions and that primary stenting should be the option for all TASC II type C and D lesions. In our case, we preferred to do the primary stenting for a better long term clinical succes and patency since our patient was presented with extensive aortoiliac lesions (TASC II type D lesion).

Tegtmeyer was the first to describe bilateral simultaneous balloon angioplasty, known as kissing balloon technique, as a potential endovascular treatment for bilateral proximal common iliac artery stenoses or focal aortic bifurcation. 15 However frequent complications occurred, such as dissections and poor angiographic and/or hemodynamic outcomes. Later, the repair of the aortic bifurcation using concurrently placed bilateral stents, known as kissing stents technique, was documented. This made the majority of aortoiliac atherosclerotic lesions amenable to percutaneous therapy. 16 Systematic review by Jebbink et al. 11 revealed that the use of kissing stent technique in AIOD had a 98.7% success rate, 10.8% complication rate, 89.9% clinical improvement achieved in 30 days, and 89.3%, 78.6%, and 69.0% primary patency rate at 12, 24, and 60 months respectively. According to the stent type, Sabri et al. 17 mentioned that for atherosclerotic aortic bifurcation occlusive disease, covered balloon-expandable kissing stents have greater patency at 2 years compared to bare metal balloon-expandable stents. Recent individual participant data meta-analysis by Bontinis, et al. 18 also reported improved 48 months patency of covered stent compared with bare metal stent in the treatment of TASC C and D lesions with 92.4% (95% CI 84.7 – 100%) and 80.8% (95% CI 64.5 – 100%) patency rate respectively. We used kissing stent technique with covered balloon-expandable stent and showed a very good result. Despite improved blood flow in short-term follow-up by CT scan and duplex ultrasound, long-term follow-up needs to be done for the patient.

 Conclusion

We presented a case of a patient with AIOD (Leriche syndrome) TASC II type D which successfully underwent endovascular treatment utilizing covered kissing stent technique with a good result and blood flow improvement to distal area of lower extremity. Endovascular approach in TASC II type C and D lesions is an excellent alternative to the traditional surgical technique.

 Research ethics and patient consent

Written informed consent has been obtained from the patient for publication of the case report and accompanying images.

 Data availability

All data underlying the results are available as part of the article and no additional source data are required.

 Acknowledgements

We would like to thank the patients for allowing us to have their cases published.

 References Kashou AH Braiteh N Zgheib A : Acute aortoiliac occlusive disease during percutaneous transluminal angioplasty in the setting of ST-elevation myocardial infarction: a case report. J. Med. Case Rep. 2018;12(1):6. 29321037 10.1186/s13256-017-1544-4 PMC5763655 Buckley B Holden A Merrilees S : 13 - Revascularization: Aortoiliac. Mauro MA Murphy KP Thomson KR , editors. Image-Guided Interventions. Boston: Elsevier; ( Third Edition).2020 (cited 2023 Feb 20); pp.99–110.e2. (Expert Radiology). 10.1016/B978-0-323-61204-3.00013-0 Reference Source Rodríguez SP Sandoval F : Aortoiliac occlusive disease, a silent syndrome. BMJ Case Rep. CP. 2019;12(7):e230770. 31311790 10.1136/bcr-2019-230770 PMC6663198 Taha AA Hefnawy ET Tawfik AR : Endovascular management of Trans-Atlantic Inter-Society Consensus C and D aortoiliac occlusive disease as a feasible, effective, and durable intervention. Egypt J. Surg. 2017;36(4):401. 10.4103/ejs.ejs_63_17 Norgren L Hiatt WR Dormandy JA : Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J. Vasc. Surg. 2007;45(1):S5–S67. 10.1016/j.jvs.2006.12.037 Aboyans V Ricco JB Bartelink MLEL : 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur. Heart J. 2018;39(9):763–816. 28886620 10.1093/eurheartj/ehx095 Jongkind V Akkersdijk GJM Yeung KK : A systematic review of endovascular treatment of extensive aortoiliac occlusive disease. J. Vasc. Surg. 2010;52(5):1376–1383. 20598474 10.1016/j.jvs.2010.04.080 Dong X Peng Z Ren Y : Endovascular treatment of aorto-iliac occlusive disease with TASC II C and D lesions: 10 year’s experience of clinical technique. BMC Cardiovasc. Disord. 2023;23(1):71. 36750924 10.1186/s12872-023-03059-4 PMC9903438 Bontinis V Bontinis A Giannopoulos A : Covered endovascular reconstruction of the aortic bifurcation: A systematic review aggregated data and individual participant data meta-analysis. J. Vasc. Surg. 2024 Jun 1;79(6):1525–1535.e9. 38104677 10.1016/j.jvs.2023.12.021 Manaki V Bontinis V Bontinis A : Bifurcated Endografts for the Treatment of Aortoiliac Disease a Systematic Review and Individual Patient Data (IPD) Meta-Analysis. J. Endovasc. Ther. 2024 Oct 7:15266028241283721. 39373576 10.1177/15266028241283721 Jebbink EG Holewijn S Slump CH : Systematic Review of Results of Kissing Stents in the Treatment of Aortoiliac Occlusive Disease. Ann. Vasc. Surg. 2017;42:328–336. 28390920 10.1016/j.avsg.2017.01.009 Yang M Zhang B Niu G : Long-term results of endovascular reconstruction for aortoiliac occlusive disease. Quant. Imaging Med. Surg. 2021;11(4):1303–1312. 33816169 10.21037/qims-20-599 PMC7930674 Klein WM Graaf Y van der Seegers J : Dutch Iliac Stent Trial: Long-term Results in Patients Randomized for Primary or Selective Stent Placement. Radiology. 2006;238(2):734–744. 10.1148/radiol.2382041053 AbuRahma AF Hayes JD Flaherty SK : Primary iliac stenting versus transluminal angioplasty with selective stenting. J. Vasc. Surg. 2007;46(5):965–970.e2. 17905559 10.1016/j.jvs.2007.07.027 Tegtmeyer CJ Kellum CD Kron IL : Percutaneous transluminal angioplasty in the region of the aortic bifurcation. The two-balloon technique with results and long-term follow-up study. Radiology. 1985;157(3):661–665. 10.1148/radiology.157.3.2932769 Sharafuddin MJ Hoballah JJ Kresowik TF : Kissing Stent Reconstruction of the Aortoiliac Bifurcation. Perspect. Vasc. Surg. Endovasc. Ther. 2008 Mar 1;20(1):50–60. 10.1177/1531003507313224 Sabri SS Choudhri A Orgera G : Outcomes of Covered Kissing Stent Placement Compared with Bare Metal Stent Placement in the Treatment of Atherosclerotic Occlusive Disease at the Aortic Bifurcation. J. Vasc. Interv. Radiol. 2010;21(7):995–1003. 20538478 10.1016/j.jvir.2010.02.032 Bontinis V Bontinis A Giannopoulos A : Editor’s Choice – Covered Stents Versus Bare Metal Stents in the Treatment of Aorto-iliac Disease: A Systematic Review and Individual Participant Data Meta-analysis. Eur. J. Vasc. Endovasc. Surg. 2024 Sep 1;68(3):348–358. 38876369 10.1016/j.ejvs.2024.06.008 10.5256/f1000research.174143.r338351 Reviewer response for version 3 Bontinis Vangelis 1 Referee https://orcid.org/0000-0001-5349-5367 Aristotle University of Thessaloniki, Thessaloniki, Greece

Competing interests: No competing interests were disclosed.

 9 11 2024 Copyright: © 2024 Bontinis V 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

The authors have adequately addressed my concerns, and I believe the article is now thoroughly updated and suitable for indexing.

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Yes

Is the case presented with sufficient detail to be useful for other practitioners?

Partly

Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Partly

Is the background of the case’s history and progression described in sufficient detail?

Partly

Reviewer Expertise:

Vascular Surgery

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

 10.5256/f1000research.168180.r333171 Reviewer response for version 2 Bontinis Vangelis 1 Referee https://orcid.org/0000-0001-5349-5367 Aristotle University of Thessaloniki, Thessaloniki, Greece

Competing interests: No competing interests were disclosed.

 25 10 2024 Copyright: © 2024 Bontinis V 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

General comments - I commend the authors for presenting an intriguing case. However, the manuscript requires careful grammatical revision, as multiple errors are evident throughout the text.

Abstract

“is a peripheral artery disease, specifically affecting the infrarenal aorta and iliac arteries.”

Comment: Rephrase since this English can be improved. A suggestion would be “ .. is a form of peripheral arterial disease involving the….”

“Presentation of AIOD patients ranged from asymptomatic to having limb-threatening emergencies “ Rephrase  

 Comment: “ The presentation of AIOD ranges from asymptomatic cases to limb-threatening emergencies”

 “Advances and innovations in endovascular devices have replaced surgical approach for AIOD treatment. Here we reported a 52-year-old man presenting with AIOD managed by endovascular approach using kissing stent technique.”

 Comment: …”have replaced traditional surgical interventions for the management of AIOD. Here we report a case of a….”

“and who was a heavy smoker”

 Comment: “and a significant history of smoking”

 “long time with bilateral claudication”

 Comment : “long-standing bilateral claudication which recently progressed to rest pain”

“He had history of aorto-infrarenal occlusion known from previous percutaneous coronary intervention from right and left femoral artery access.”

 Comment: “A history of aortoiliac occlusive disease (TASC II Type D) was previously established”

 optimal medical treatment

 Comment “best medical therapy (BMT)”

“Treatment of AIOD should include both modification of risk factors and efforts to increase perfusion to the lower extremities. An endovascular approach is an excellent alternative and may replace surgical approach in complex aortoiliac obstructive disease. In this case report, an endovascular approach with kissing stent technique showed good results for the patient.”

 Comment: You can’t just pop up a comment about risk modification parameters out of nowhere. Then you just performed a case of a kissing stent you can’t claim that just because of this one case endovascular techniques will surpass surgical interventions. These conclusions are merely grounded on your limited persona experience

A suggested rephrase is “Endovascular interventions present excellent alternatives to surgical techniques in the treatment of complex aortoiliac obstructive disease. Herein we presented, an endovascular treatment of AIOD utilizing the kissing stent technique which showcased satisfactory outcomes.”

Introduction

 

 “is the leading cause of peripheral arterial disease (PAD)”

Comment: About 1/3 of PAD cases present with aortoiliac involvement and very few of them are complete occlusions! The most common distribution of PAD lesions involve femoropopliteal lesions!

 

“ nicotine use, age, sex, and family history”

Comment: you mean “male gender”

 

“ Advances and innovations in endovascular devices have replaced standard surgical approach with endovascular approach, including in long and complex lesions. An endovascular approach is currently recommended as the definitive interventional treatment for AIOD”

Comment: First avoid repeating the same words within a sentence. Then, no they have not replaced surgical techniques and they are not recommended over surgery. As a matter of fact, this is much more complicated than you suggest with TASC guidelines suggesting endovascular surgery for TASC A and B lesions and surgery for TASC C D lesions (which include occlusions). Additionally, more recent guidelines advocate for endovascular treatment in short lesions or occlusions. So please correct this

Case report

“Javanese man”

Comment: I believe the authors mean "Japanese"

 

“ bilateral leg pain in the”

Comment: You mean claudication or rest pain?

 

“He had symptoms of worsening bilateral leg pain in the past year, and felt chest pain sometimes, especially when he was walking for long distances. Another clinical symptom that he had was impotence. “

Comment: This English can be improved and a suggested rephrase would be “Over the past year, the patient experienced progressive bilateral leg pain, accompanied by occasional episodes of chest pain, particularly during prolonged walking. Additionally, the patient reported symptoms of erectile dysfunction.”

 

“ The patient had a history of aorto-infrarenal occlusion that was known when he underwent percutaneous coronary intervention (PCI)  via the right radial artery but failed after the approach was moved to both sides of femoral artery access because of the occlusion in bilateral common iliac arteries one year earlier. “

Comment: This paragraph fails to provide any clarity unfortunately. In my opinion the fact that he had an attempt to PCI and they it failed is of no true value to the manuscript. You can just state that the patient had known AOID diagnosed following a failed PCI attempt.

 

“ Insertion of 12×95×100 mm bifurcated stent graft extension (Seal ®, S&G Biotech, Korea) from the right femoral artery access and 12×75×80 mm bifurcated stent graft extension (Seal ®, S&G Biotech, Korea) from the left femoral artery access were done ( Figure 2F)”

Comment: What I see here are covered stents and not bifurcated grafts which in reality you could not have used so please correct this as this is a major error!

 

“ The final result of the procedure was positive flow until the distal part of both common femoral”

Comment: There is no such thing as a positive or negative flow. Omit this while sentence and just state “Following the intervention abdominal aorta blood pressure was 170 / 79 (114) mmHg, right femoral artery blood pressure was 141/68 (98) mmHg, and left femoral artery blood pressure was 137/77 (102) mmHg”

 

“ Lower extremity CTA revealed patent kissing stent graft”

Comment: Kissing stents are not grafts they are just kissing stents

 

 positive flow to bilateral femoral artery, bilateral subpopliteal artery, until bilateral malleolus region especially left anterior tibial artery and right posterior tibial artery

Comment: Again there is not such a thing as positive flow. There is either presence of flow (monophasic biphasic signal on doppler) or presence or absence of pulses. Please state which one was in your case. There is not an artery called subpopliteal, there are however infrapopliteal artreies (anterio, posterior tibial and peroneal)

Discussion

 

Comment: Endovascular techniques is a general term in your first paragraph you should report on the available endovascular techniques including CERAB and unibody endografts. Also update you reference list accordingly -

1. (Bontinis V et al. [2024 (Ref - 1)]) DOI: 10.1016/j.jvs.2023.12.021,

2. (Manaki V et al. [2024 (Ref - 2)]) DOI: 10.1177/15266028241283721

 

Sabri et al.15 mentioned that for atherosclerotic aortic bifurcation occlusive disease, covered balloon-expandable kissing stents have greater patency at 2 years compared to bare metal balloon-expandable stents. We used kissing stent technique with covered balloon-expandable stent and showed a very good result. Despite improved blood flow in short-term follow-up by CT scan and duplex ultrasound, long-term follow-up needs to be done for the patient.

Comment: Update your references list with the latest IPD meta-analysis describing Covered VS Bare for aotoiliac disea with follow-up intervals up to 10 years (Bontinis V et al. [2024 (Ref - 3)]) 10.1016/j.ejvs.2024.06.008

 

“ In our case, the patient was a heavy smoker, but he admitted that he just committed to stop smoking. Unfortunately, he had long-standing hypertension and type 2 DM which also were another important risk factor of atherosclerosis process itself. Good teamwork between care provider, patient, and patient’s family should be targeted in this scenario.”

Comment: You are presenting a technical manuscript and this is irrelevant in my opinion

Conclusion

“We had presented a case of a patient with AIOD (Leriche syndrome) TASC II type D which successfully underwent endovascular approach (kissing stent technique) with a good result and blood flow improvement to distal area of lower extremity.

Comment : “We presented”, “covered kissing stent technique”,

 

Endovascular management of TASC II type C and D lesions approach is an excellent alternative to the surgical approach The word approach is redundant

Comment : the word approach is out of place here

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Yes

Is the case presented with sufficient detail to be useful for other practitioners?

Partly

Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Partly

Is the background of the case’s history and progression described in sufficient detail?

Partly

Reviewer Expertise:

Vascular Surgery

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

References : Covered endovascular reconstruction of the aortic bifurcation: A systematic review aggregated data and individual participant data meta-analysis. J Vasc Surg .2024;79(6) : 10.1016/j.jvs.2023.12.021 1525-1535.e9 38104677 10.1016/j.jvs.2023.12.021 : Bifurcated Endografts for the Treatment of Aortoiliac Disease a Systematic Review and Individual Patient Data (IPD) Meta-Analysis. J Endovasc Ther .2024; 10.1177/15266028241283721 15266028241283721 39373576 10.1177/15266028241283721 : Editor's Choice - Covered Stents Versus Bare Metal Stents in the Treatment of Aorto-iliac Disease: A Systematic Review and Individual Participant Data Meta-analysis. Eur J Vasc Endovasc Surg .2024;68(3) : 10.1016/j.ejvs.2024.06.008 348-358 38876369 10.1016/j.ejvs.2024.06.008 Taofan Taofan National Cardiovascular Center Harapan Kita, Indonesia

Competing interests: no ompeting interest

 28 10 2024

We would like to thank Dr. Vangelis Bontinis for the constructive insight regarding our manuscript. Here we try to adress and revise our manuscript from Dr. Vangelis Bontinis comments point by point.

Abstract

1. “is a peripheral artery disease, specifically affecting the infrarenal aorta and iliac arteries.” Comment: Rephrase since this English can be improved. A suggestion would be “ .. is a form of peripheral arterial disease involving the….”

The sentence has been paraphrased to “Aortoiliac occlusive disease (AIOD) or Leriche syndrome, is a form of peripheral arterial disease involving the infrarenal aorta and iliac arteries.”

2. “Presentation of AIOD patients ranged from asymptomatic to having limb-threatening emergencies “ Rephrase. Comment: “ The presentation of AIOD ranges from asymptomatic cases to limb-threatening emergencies”

The sentence has been paraphrased to “The presentation of AIOD ranges from asymptomatic cases to limb-threatening emergencies.

3. “Advances and innovations in endovascular devices have replaced surgical approach for AIOD treatment. Here we reported a 52-year-old man presenting with AIOD managed by endovascular approach using kissing stent technique.” Comment: …”have replaced traditional surgical interventions for the management of AIOD. Here we report a case of a….”

The sentences have been paraphrased to “Advances and innovations in endovascular devices have replaced traditional surgical interventions for the management of AIOD. Here we report a case of a 52-year-old man presenting with AIOD managed by endovascular approach using kissing stent technique.”

4. “and who was a heavy smoker” Comment: “and a significant history of smoking”. “long time with bilateral claudication” Comment : “long-standing bilateral claudication which recently progressed to rest pain”

The sentence has been paraphrased to “A 52-year-old man, with history of chronic coronary artery disease, diabetes mellitus type 2, long-standing hypertension, and a significant history of smoking, was admitted to our hospital with symptoms of long-standing bilateral claudication which recently progressed to rest pain.”

5. “He had history of aorto-infrarenal occlusion known from previous percutaneous coronary intervention from right and left femoral artery access.” Comment: “A history of aortoiliac occlusive disease (TASC II Type D) was previously established”

The sentences have been paraphrased to “A history of AIOD was previously established. AIOD (TASC II Type D) diagnosis was made by lower extremity duplex ultrasound and CT angiography.”

6. optimal medical treatment, Comment “best medical therapy (BMT)”

The sentence has been paraphrased to “The patient was discharged 4 days after the procedure without any significant complaints, received best medical therapy.”

7. “Treatment of AIOD should include both modification of risk factors and efforts to increase perfusion to the lower extremities. An endovascular approach is an excellent alternative and may replace surgical approach in complex aortoiliac obstructive disease. In this case report, an endovascular approach with kissing stent technique showed good results for the patient.” Comment: You can’t just pop up a comment about risk modification parameters out of nowhere. Then you just performed a case of a kissing stent you can’t claim that just because of this one case endovascular techniques will surpass surgical interventions. These conclusions are merely grounded on your limited persona experience A suggested rephrase is “Endovascular interventions present excellent alternatives to surgical techniques in the treatment of complex aortoiliac obstructive disease. Herein we presented, an endovascular treatment of AIOD utilizing the kissing stent technique which showcased satisfactory outcomes.”

The sentences have been paraphrased to Endovascular interventions present excellent alternatives to surgical techniques in the treatment of complex AIOD. Herein we presented an endovascular treatment of AIOD utilizing the kissing stent technique which showcased satisfactory outcomes.

Introduction

8. “is the leading cause of peripheral arterial disease (PAD)” Comment: About 1/3 of PAD cases present with aortoiliac involvement and very few of them are complete occlusions! The most common distribution of PAD lesions involve femoropopliteal lesions!

The sentence has been paraphrased to “Aortoiliac occlusive disease (AIOD), also known as Leriche syndrome results from a chronic occlusive process of the infrarenal aorta and iliac arteries and is one of the cause of peripheral arterial disease (PAD).”

9. “ nicotine use, age, sex, and family history” Comment: you mean “male gender”

The sentence has been paraphrased to “Risk factors for AIOD include hypertension, hyperglycemia, hyperlipidemia, nicotine use, age, male gender, and family history.”

 

10. “ Advances and innovations in endovascular devices have replaced standard surgical approach with endovascular approach, including in long and complex lesions. An endovascular approach is currently recommended as the definitive interventional treatment for AIOD” Comment: First avoid repeating the same words within a sentence. Then, no they have not replaced surgical techniques and they are not recommended over surgery. As a matter of fact, this is much more complicated than you suggest with TASC guidelines suggesting endovascular surgery for TASC A and B lesions and surgery for TASC C D lesions (which include occlusions). Additionally, more recent guidelines advocate for endovascular treatment in short lesions or occlusions. So please correct this

The sentences have been paraphrased to “Advances and innovations in endovascular devices offered promising alternatives over standard surgical approach, including in long and complex lesions. Endovascular treatment in the aortoiliac segment has shown high technical success and lower complication rates compared to standard surgery. It also provides excellent patency, making it a valuable option to be considered for Trans-Atlantic Inter-Society Consensus (TASC) C and D lesions, especially in patients who are poor candidates for surgery.”

 

Case report

11. “Javanese man” Comment: I believe the authors mean "Japanese"

Javanese is an ethnic group from Indonesia. It is who we identify as.

12. “ bilateral leg pain in the” Comment: You mean claudication or rest pain? “He had symptoms of worsening bilateral leg pain in the past year, and felt chest pain sometimes, especially when he was walking for long distances. Another clinical symptom that he had was impotence. “ Comment: This English can be improved and a suggested rephrase would be “Over the past year, the patient experienced progressive bilateral leg pain, accompanied by occasional episodes of chest pain, particularly during prolonged walking. Additionally, the patient reported symptoms of erectile dysfunction.”

The sentences have been paraphrased to “Over the past year, the patient experienced long-standing bilateral claudication which recently progressed to rest pain, accompanied by occasional episodes of chest pain, particularly during prolonged walking. Additionally, the patient reported symptoms of erectile dysfunction.”

 

13. “ The patient had a history of aorto-infrarenal occlusion that was known when he underwent percutaneous coronary intervention (PCI) via the right radial artery but failed after the approach was moved to both sides of femoral artery access because of the occlusion in bilateral common iliac arteries one year earlier. “ Comment: This paragraph fails to provide any clarity unfortunately. In my opinion the fact that he had an attempt to PCI and they it failed is of no true value to the manuscript. You can just state that the patient had known AOID diagnosed following a failed PCI attempt.

The sentence has been paraphrased to “The patient had  known AOID diagnosed following a failed percutaneous coronary intervention (PCI) attempt.”

14. “ Insertion of 12×95×100 mm bifurcated stent graft extension (Seal®, S&G Biotech, Korea) from the right femoral artery access and 12×75×80 mm bifurcated stent graft extension (Seal®, S&G Biotech, Korea) from the left femoral artery access were done (Figure 2F)” Comment: What I see here are covered stents and not bifurcated grafts which in reality you could not have used so please correct this as this is a major error!

It has been corrected to “Insertion of 12×95×100 mm stent graft (Seal ®, S&G Biotech, Korea) from the right femoral artery access and 12×75×80 mm stent graft (Seal ®, S&G Biotech, Korea) from the left femoral artery access were done.”

15, “ The final result of the procedure was positive flow until the distal part of both common femoral” Comment: There is no such thing as a positive or negative flow. Omit this while sentence and just state “Following the intervention abdominal aorta blood pressure was 170 / 79 (114) mmHg, right femoral artery blood pressure was 141/68 (98) mmHg, and left femoral artery blood pressure was 137/77 (102) mmHg”

The sentence has been paraphrased to “Following the intervention abdominal aorta blood pressure was 170 / 79 (114) mmHg, right femoral artery blood pressure was 141/68 (98) mmHg, and left femoral artery blood pressure was 137/77 (102) mmHg.”

16. “ Lower extremity CTA revealed patent kissing stent graft”. Comment: Kissing stents are not grafts they are just kissing stents.  Positive flow to bilateral femoral artery, bilateral subpopliteal artery, until bilateral malleolus region especially left anterior tibial artery and right posterior tibial artery Comment: Again there is not such a thing as positive flow. There is either presence of flow (monophasic biphasic signal on doppler) or presence or absence of pulses. Please state which one was in your case. There is not an artery called subpopliteal, there are however infrapopliteal artreies (anterio, posterior tibial and peroneal)

The sentences have been paraphrased to “Lower extremity CTA revealed patent kissing stent graft at bilateral common iliac artery, positive contrast flow was presence to bilateral femoral artery, bilateral infrapopliteal artreies subpopliteal artery, until bilateral malleolus region especially left anterior tibial artery and right posterior tibial artery.”

Discussion

17. Comment: Endovascular techniques is a general term in your first paragraph you should report on the available endovascular techniques including CERAB and unibody endografts. Also update you reference list accordingly - 1.  (Bontinis V et al. [2024 (Ref - 1)]) DOI: 10.1016/j.jvs.2023.12.021, 2. (Manaki V et al. [2024 (Ref - 2)]) DOI: 10.1177/15266028241283721

Available endovascular techniques have been mentioned in the paragraph: “Several available reported endovascular techniques for AIOD treatments including covered endovascular reconstruction of the aortic bifurcation (CERAB), unibody bifurcated endografts, and kissing stent technique showed promising patency outcomes.”

 

18. Sabri et al.15 mentioned that for atherosclerotic aortic bifurcation occlusive disease, covered balloon-expandable kissing stents have greater patency at 2 years compared to bare metal balloon-expandable stents. We used kissing stent technique with covered balloon-expandable stent and showed a very good result. Despite improved blood flow in short-term follow-up by CT scan and duplex ultrasound, long-term follow-up needs to be done for the patient. Comment: Update your references list with the latest IPD meta-analysis describing Covered VS Bare for aotoiliac disea with follow-up intervals up to 10 years (Bontinis V et al. [2024 (Ref - 3)]) 10.1016/j.ejvs.2024.06.008

Reference has been updated mentioning IPD meta-analysis by Bontinis V, et al. “Recent individual participant data meta-analysis by Bontinis, et al. also reported improved 48 months patency of covered stent compared with bare metal stent in the treatment of TASC C and D lesions with 92.4% (95% CI 84.7 – 100%) and 80.8% (95% CI 64.5 – 100%) patency rate respectively.”

 

19. “ In our case, the patient was a heavy smoker, but he admitted that he just committed to stop smoking. Unfortunately, he had long-standing hypertension and type 2 DM which also were another important risk factor of atherosclerosis process itself. Good teamwork between care provider, patient, and patient’s family should be targeted in this scenario.” Comment: You are presenting a technical manuscript and this is irrelevant in my opinion

The paragraph has been removed from the manuscript

Conclusion

20. “We had presented a case of a patient with AIOD (Leriche syndrome) TASC II type D which successfully underwent endovascular approach (kissing stent technique) with a good result and blood flow improvement to distal area of lower extremity. Comment : “We presented”, “covered kissing stent technique”, Endovascular management of TASC II type C and D lesions approach is an excellent alternative to the surgical approach The word approach is redundant Comment : the word approach is out of place here

The sentences have been paraphrased to “We presented a case of a patient with AIOD (Leriche syndrome) TASC II type D which successfully underwent endovascular treatment utilizing( covered kissing stent technique) with a good result and blood flow improvement to distal area of lower extremity. Endovascular approach of in TASC II type C and D lesions is an excellent alternative to the traditional surgical technique.”

Once again, I really appreciate the time and effort that you have invested in reviewing my manuscript. Your insights were helpful, and I am truly grateful for your support and expertise. Please let us know if further revision is needed. Thank you for your contribution to our manuscript.

Best regards,

Taofan, MD

Departement of Cardiology and Vascular Medicine Faculty of Medicine Universitas Indonesia

 10.5256/f1000research.168180.r299453 Reviewer response for version 2 Habibie Yopie Afriandi 1 Referee https://orcid.org/0000-0003-1007-3097 Department of Surgery, Faculty of Medicine Universitas Syiah Kuala (Ringgold ID: 175503), Banda Aceh, Aceh, Indonesia

Competing interests: No competing interests were disclosed.

 15 7 2024 Copyright: © 2024 Habibie YA 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

Dear Dr. Taofan and Team

I appreciate your dedication to enhancing this manuscript to advance knowledge.

Congratulations to Dr. Taofan and the team.

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Partly

Is the case presented with sufficient detail to be useful for other practitioners?

Yes

Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Partly

Is the background of the case’s history and progression described in sufficient detail?

Yes

Reviewer Expertise:

Cardiovascular Medicine, Vascular Surgery, Endovascular, Thoracic Surgery, Cardiac Surgery, Acute Care Surgery, Trauma

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Taofan Taofan National Cardiovascular Center Harapan Kita, Indonesia

Competing interests: No competing interests were disclosed.

 3 9 2024

Dear Yopie Afriandi Habibie

I hope this message finds you well.

I wanted to extend my sincere gratitude for your thoughtful and thorough review of my article, “Case Report: Endovascular approach with kissing stent technique in aortoiliac occlusive disease (Leriche syndrome) patient” which has been approved for publication in F1000research. Your valuable feedback and constructive comments significantly contributed to the enhancement of my work.

I greatly appreciate the time and effort you invested in reviewing my manuscript. Your insights were incredibly helpful, and I am truly grateful for your support and expertise.

Thank you once again for your contribution to the successful publication of my article. I look forward to any future opportunities for collaboration.

Best regards,

Taofan, MD

Departement of Cardiology and Vascular Medicine Faculty of Medicine Universitas Indonesia

 10.5256/f1000research.146357.r252298 Reviewer response for version 1 Habibie Yopie Afriandi 1 Referee https://orcid.org/0000-0003-1007-3097 Department of Surgery, Faculty of Medicine Universitas Syiah Kuala (Ringgold ID: 175503), Banda Aceh, Aceh, Indonesia

Competing interests: No competing interests were disclosed.

 25 5 2024 Copyright: © 2024 Habibie YA 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

Case Report:

1. Please describe the duration of the symptoms and the specific symptoms experienced by the patient during the course related to the AIOD.

2. Can you provide more specific details about the vascular examination related to AIOD?

3. In the third paragraph, please correct the diagnosis to Chronic Limb Threatening Ischemia (TASC II Type D lesion).

4. In the fifth paragraph, please explain how you performed initial orthography in this patient, despite an AIOD? Did you puncture both sides of the Femoral artery? Please explain step by step the procedure before implanting the kissing stent. Also, which wire did you use to penetrate the lesion? For balloon pre-dilatation, which Fr did you use (Fig 2C and D)?

5. Regarding Fig 2H, do you have another image after the final result showing the stent's patency?

Discussion

1. Paragraph two last sentence: Please explain your reasoning for choosing primary stenting over selective stenting despite the risks.

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Partly

Is the case presented with sufficient detail to be useful for other practitioners?

Yes

Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Partly

Is the background of the case’s history and progression described in sufficient detail?

Yes

Reviewer Expertise:

Cardiovascular, Vascular & Endovascular Surgery, Vascular Medicine, Thoracic Trauma, Trauma, Stem Cell, Cardiac Surgery, Thoracic Disease,

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Taofan Taofan National Cardiovascular Center Harapan Kita, Indonesia

Competing interests: no competing interest

 20 6 2024

Thank you for the constructive insight into our article. Here we try to answer and revise some of the questions and notes from the reviewer.

Case Report:

1. Please describe the duration of the symptoms and the specific symptoms experienced by the patient during the course related to the AIOD.

The patient experienced the symptomps in the past year and his PCI was done one year earlier.

2. Can you provide more specific details about the vascular examination related to AIOD?

Lower extremity duplex ultrasound (DUS) suspected significant stenosis of the abdominal aorta at the infra-renal level with high end-diastolic monophasic doppler curve in both external iliac artery and common femoral artery, rounded doppler curve in both popliteal, anterior, and posterior tibial artery, no thrombus in the deep veins in both limbs, and positive arterial flow to distal to both legs.

Pletismography examination revealed Rright ABI was 0.42 and left was 0.35, right toe brachial index (TBI) was 0.45 and left 0.49.

3. In the third paragraph, please correct the diagnosis to Chronic Limb Threatening Ischemia (TASC II Type D lesion).

The diagnosis has been revised into chronic limb threatening ischaemia (TASC II type D lesion) causing bilateral aortic infrarenal–iliaca occlusion (Leriche syndrome).

4. In the fifth paragraph, please explain how you performed initial orthography in this patient, despite an AIOD? Did you puncture both sides of the Femoral artery? Please explain step by step the procedure before implanting the kissing stent. Also, which wire did you use to penetrate the lesion? For balloon pre-dilatation, which Fr did you use (Fig 2C and D)?

A more detailed step by step procedure with the device used has been described in the paragraph.

5. Regarding Fig 2H, do you have another image after the final result showing the stent's patency?

We have changed the Fig 2H, hope it can show clearer image of the final result.

Discussion

1. Paragraph two last sentence: Please explain your reasoning for choosing primary stenting over selective stenting despite the risks.

In our case, we preferred to do the primary stenting for a better long term clinical succes and patency since our patient was presented with extensive aortoiliac lesions (TASC II type D lesion).

Once again thanks to Dr. Yopie Afriandi Habibie for the time and effort in reviewing our article, please let us know if further revision is needed.