CERAB Emerges as the Aortoiliac Favorite

The use of covered stents in complex aortoiliac peripheral artery occlusive disease (POD) lesions and fenestrated/branched endovascular aneurysm repair (FEVAR/BEVAR) was discussed on Monday afternoon by Markus Steinbauer, MD, a vascular surgeon and head of the department of vascular surgery at Krankenhaus Barmherzige Brüder in Regensburg, Germany. Dr. Steinbauer, who is also the president of the German Society of Vascular Surgery, recalled working with stents back at the beginning of the 2000s. “This was the first step we used for the complex aortic reconstructions with FEVAR and BEVAR,” he told LINC Today. “But then we learned that, especially in complex lesions of the iliacs, covered stents are actually more successful in treating these lesions than bare metal stents.”

Dr. Steinbauer said his move to covered stents was inspired by seeing the results of work by Peter Goverde, MD, of the Vascular Clinic ZNA in Antwerp, Belgium. Dr. Goverde devised the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) procedure with a complex reconstruction of the aortoiliac system using a covered stent in the aorta and two covered stents in the iliacs. “And so we learned that this kind of stent has specific properties and is very versatile to use either in aortic lesions as well as in POD lesions of the aortoiliac system,” he said.

Monday’s presentation covered the latest on this CERAB technique, particularly the versatility of the PTFE covered stent in POD and BEVAR. “So for all indications, I wanted to show what this device is able to do,” he said. “Most of the data I can present is based on POD and the complex lesions –TASC II C and D lesions, with aortoiliac obstructions,” he said.

Dr. Steinbauer shared literature about the CERAB procedure and specific cases which show the possibilities of the stent. Because there is still no meta-analysis on the CERAB (the procedure is so complex) Dr. Steinbauer talked about 2 separate studies as well as his own group’s work. “They are only single-center studies,” he said. “We have some patients—perhaps not as many as many other big centres but I think it's interesting for those focused on this specific type of lesion, which is highly complex.”

Dr. Steinbauer predicts that LINC delegates might suggest the kissing balloon technique is more appropriate than CERAB. “But this should depend on the size of the aortic lesion. If you have small aortic lesions you can use a kissing balloon with covered stents,” he said. “But if there is more occlusion of the bifurcation then the CERAB procedure is definitely the most successful treatment in this specific indication.”

The CERAB technique is becoming more popular, Dr. Steinbauer went on, but there are concerns. “What I fear is that some may use this technique for other indications,” he said. “It’s a very good technique for POD patients, but not for all aortoiliac diseases.

“For aneurysmal disease or penetrating aortic ulcers, this is not the best way to use it.” Aneurysmal diseases can be treated with normal endovascular treatments – an endograft is definitely safer than using CERAB, he said. “We have some centers that treat aneurysmal disease with the CERAB technique. It’s good, but it shouldn't be overstretched.”

It’s been a gradual but fascinating evolution, noted Dr. Steinbauer, who saw the very first stent graft develop over the years into a stent graft as a side arm of FEVAR and BEVAR, and then to a central stent graft for the complex treatment of POD and aortoiliac lesions. “Now, especially with this CERAB procedure, we have a good tool for a small number of patients with very severe aortoiliac lesions in POD,” he concluded.