Propensity Matched Cohorts Comparison of Endovascular Repair Using Kissing Self-expanding Covered Stents with Open Aorto-Bi-Femoral Bypass for the Treatment of Severe Aorto-Iliac Occlusive Disease

Abstract

Introduction: In patients with complex aortoiliac occlusive disease (AIOD), Self-Expanding Covered Stents (SECS) have been employed to reconstruct the aortic bifurcation and re-establish a normal iliac flow (fig.1). Aim of the study was to retrospectively compare the outcomes of this endovascular technique with open aortobifemoral bypass (ABF) in severe AIOD, using propensity score matching. Methods: A single-center retrospective analysis of patients treated by SECS or ABF repair for TASC-II C/D lesions from 2009 to 2018 was carried out. Indication to treatment was severe claudication or critical limb ischemia. The Society for Vascular Surgery (SVS) comorbidity grading system and ASA score were used as perioperative risk scores. The kissing stent technique consisted in the deployment of two parallel SECS covering the distal aorta (≥1.5 cm) and both iliac arteries, with a systematic balloon pre- and post-dilatation. Thirty-day outcomes and mid-term patency were compared in unmatched and propensity-matched cohorts; follow-up results were analyzed with Kaplan-Meier curves. Cox proportional hazards were used to identify independent predictors of patency. Results: SECS technique was employed in 63 and ABF in 55 patients respectively. The SECS group was characterized by higher grade of comorbidities (ASA score, 3.0±0, vs 2.9±0.3; P=.012. SVS score, 1.01±0.5 vs 0.79±0.5; P=.012), less advanced disease (TASC D lesions, 52.3% vs 72.7%; P=.036) and a lower number of iliac total occlusions (46.8% vs 87.2%; P=.024). After propensity score matching, 148 limbs were selected, 74 SECS and 74 ABF. No difference was observed between the two matched groups, regarding perioperative risk (ASA score, 3.0±0 vs 2.9±0.1; P=.514. SVS score, 0.97±0.5 vs 0.88±0.5; P=.373), TASC classification (TASC D lesions, 60.4% vs 63.0%; P=.516) and iliac occlusions (SECS: 47.3% vs 59.5%; P=.0187), as also clinical presentation (Rutherford category, P=.693). The SECS group showed a significantly shorter hospital (4.1±5.6 days vs 9.5 ± 5.2 days; P< .001) and ICU stay (0±0.1 days vs 1.7±1.4 days; P< .001), as well as a lower surgical complication rate (4.7% vs 12.7%; P=.035), that were confirmed in the matched cohort (hospital stay, P< .001; ICU stay, P< .001; surgical complications, P=.046). Primary patencies at 5 years were 86.9% and 87.3% for the SECS and ABF group respectively (P=.690); this result was confirmed also in the matched cohort (SECS: 84.1%, ABF: 88.3%; P=.454, Fig. 2). Multivariate analysis showed that Rutherford category was the only independent predictor of primary patency both in the unmatched (HR 3.96, P=.001) and matched cohort (HR 4.1, P=.023). Conclusion: The endovascular kissing SECS technique for severe aorto-iliac obstructive lesions presented a remarkable primary patency, equal to ABF at 5 years, and may be considered as a valid alternative of open surgical treatment.Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: Nothing to disclose