Endovascular Versus Open Treatment of Severe Aortoiliac Occlusive Disease: Outcomes of Kissing Self-Expanding Covered Stent for Reconstruction of the Aortic Bifurcation

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Introduction - Self-Expanding Covered Stents (SECS) have been employed to reconstruct the aortic bifurcation and re-establish a normal iliac flow in patients with complex aortoiliac occlusive disease (AIOD), classified as TASC-II type C and D. Aim of the study was to retrospectively compare SECS with aortobifemoral bypass (ABF) in TASC-II C and D AIOD lesions. Primary endpoints were perioperative and mid-term results. Preoperative risk factors, clinical and anatomical presentations were analysed Methods - A prospectively maintained database was searched for TASC-II C/D AIOD patients, treated with SECS or ABF. Indication to treatment was severe claudication or critical limb ischemia (Rutherford categories). Operative comorbidity risk was assessed using the Society for Vascular Surgery (SVS) comorbidity grading system. SECS technique consisted on bilateral femoral approach (percutaneous or open), retrograde or antegrade lesion crossing, pre-dilatation using small-diameter balloons, kissing SECS deployment in the aortoiliac lesions and final post-dilatation to the appropriate diameter. SECS included Viabahn (Gore) and Fluency (Bard) grafts. Concomitant femoral artery endoarterectomy was performed in both groups, when needed. Clinical and duplex-scan evaluation was performed at 3-6-12 months and then yearly. Statistical analyses were performed using the Free Software R. Results - From January 2009 to November 2016, 100 consecutive patients were included in the study (50 SECS and 50 ABF). No difference was observed between the two groups, regarding preoperative Rutherford category distribution (p-value=0.39). SECS group showed significant less advanced TASC lesions (27 vs 42 TASC D, p-value = 0.002) and significant greater total SVS comorbidity score (1 ± 0.53 vs 0.79 ± 0.46, p-value=0.047). Cumulative perioperative surgical complications were 5% in SECS and 6% in ABF group, whereas medical complications were 2% in SECS and 10% in ABF, including 1 death (p-value=0.20). The mean follow-up was 27±21 months. Kaplan-Meyer analysis (fig.1) showed a primary patency estimate of 94.9% (95% CI, 89-100) and 89.2% (95% CI, 81-99) in SECS and ABF group respectively (p-value=0.85). Based on a Cox proportional hazard regression analysis, among all preoperative variables only Rutherford Category (HR =3.04, P = 0.01) and SVS score (HR=0.22, P=0.10) proved to be prognostic factors of primary patency. Similarly, a logistic regression model with dependent variable patency indicated as significant factors only Rutherford Category (P = 0.02) and SVS score (P=0.05). Conclusion - Endovascular treatment using SECS showed no statistical difference in perioperative and follow-up results as compared to open repair. Rutherford category and SVS score were the only variables able to influence long-term follow-up results.