Balloon-Assisted Remote External Iliac Artery Endarterectomy: A Safe and Durable Technique for the Treatment of Iliac Artery Occlusive Disease

Abstract

Historically, the treatment of iliac artery occlusive disease required a surgical bypass usually consisting of an aortobifemoral bypass or an iliofemoral bypass. With the advent of balloon angioplasty and stenting, these procedures are frequently replaced with endovascular options. However, the treatment of diffuse occlusive disease of the external iliac artery (EIA) does not carry a favorable long-term patency rate using balloon angioplasty and/or stenting. Remote endarterectomy of the EIA using ring dissectors with balloon assistance provides a novel, controlled, safe, and durable treatment of the diseased and/or occluded EIA. A retrospective review over the past 5 years was performed at our institution identifying patients treated with balloon-assisted remote endarterectomy of the EIA by the current five practicing vascular surgeons. The technique involves exposure of the ipsilateral common femoral artery. With nonoccluded disease, direct access into the common femoral artery is performed, a wire is traversed through the diseased EIA, and a balloon is inflated at the origin of this vessel to provide hemostasis and control. A femoral endarterectomy is performed and a ring dissector is passed over the endarterectomized material including the wire and balloon catheter, and advanced remotely through the EIA up to the balloon. The balloon is briefly deflated and repositioned within the ring dissector and reinflated, thus cutting the plaque and allowing for retraction of the inflated balloon and cutter, removing the endarterectomized core plaque. The procedure is similar for the treatment of an occluded EIA, but wire access across the occluded vessel is normally achieved with contralateral access. In both cases, the balloon provides control and hemostasis and is critically important in the rare treatment of vessel rupture. A total of 78 vessels were treated in 74 patients. The procedure was successful in 76 of the vessels with failure related to vessel rupture requiring conversion to an iliofemoral bypass. The primary patency was 97% with a mean follow-up of 28 months. Restenosis in the two patients seemed to be related to a severe sclerotic response. The EIA was occluded 38% of the time. The common iliac artery (CIA) was diseased requiring angioplasty and stenting 28% of the time and a stent was place at the transition zone between endarterectomized vessel and nontreated proximal most EIA or distal most CIA 59% of the time. There were no perioperative deaths. Balloon-assisted remote endarterectomy of the diffusely diseased and or occluded EIA is a safe and durable option. It precludes the need for a prosthetic conduit and the risk of associated infection. It involves a single groin incision, negating the need for retroperitoneal exposure of the CIA.