Reply

Abstract

The comments made by Drs Luján, Criado, Izquierdo, and Puras are much appreciated and only point to the complex nature determining iliac artery stent patency and overall outcomes. Our retrospective study was originally borne out of a disagreement between the interventional radiology and vascular surgery departments regarding the long-term patency rates and overall efficacy of external iliac artery stents. The bias in the vascular surgery department had been that external iliac artery stents had poor patency rates and did little to affect outcome. However, after a search of the literature, little information could be found regarding stents placed in the external iliac artery. The only information available was author reports examining risk factors for iliac artery stent failure. In these multivariate analyses, placement of a stent in the external iliac did not increase the risk for early stent failure. However, concerns of inadequate patient numbers (type II error) were always raised as a caveat in the discussion. To our knowledge, our manuscript is the first description of overall patency in the external iliac artery with a direct comparison to the patency of the common iliac artery. We disagree on several points brought up by Drs Luján and colleagues. We are unclear about what is meant by the “lack of essential data to ascertain that both groups are comparable are not provided...” We used the recommended standards for reports dealing with lower extremity ischemia: the revised version1Rutherford RB Baker JD Ernst C Johnston KW Porter JM Ahn S et al.Recommended standards for reports dealing with lower extremity ischemia: revised version.J Vasc Surg. 1997; 26: 517-538Abstract Full Text Full Text PDF PubMed Scopus (2496) Google Scholar to compare levels of ischemia and to grade known risk factors within groups of patients. This information was clearly shown in tables within our manuscript. The omission of failed attempts at stent placement is a weakness of our study, and we wish we could report those data in our manuscript. However, several papers have shown that initial success rates should be high at around 98% to 100%, so failing to identify the patients that were unsuccessfully stented probably does not affect the overall conclusions of our study. Dr Luján and colleagues also mention our failure to include hemodynamic criteria in our manuscript. However, by reporting “anatomic patency,” we did meet the recommended standards1Rutherford RB Baker JD Ernst C Johnston KW Porter JM Ahn S et al.Recommended standards for reports dealing with lower extremity ischemia: revised version.J Vasc Surg. 1997; 26: 517-538Abstract Full Text Full Text PDF PubMed Scopus (2496) Google Scholar for reporting patency rates, that is, “patency rates [should be] based on objective findings, like arteriography, duplex ultrasound, or magnetic resonance imaging.” Nevertheless, the inclusion of hemodynamic information is an interesting one but still does not completely answer the ultimate question: Do external iliac artery stents improve overall outcomes? Although hemodynamic data are other indicators of stent patency, we feel more information regarding stent success should be used such as improvement in foot ulcers, symptomatic relief in rest pain, improvement in treadmill exercise tests, and, ultimately, an improvement in overall quality of life should also be included. Since common iliac artery stenting is a generally accepted mode of therapy, we simply compared our own institutional outcome of common iliac artery stents with that of the external iliac artery stents using one objective standard, angiographic or duplex ultrasound analysis. In doing so we were able to establish that placing external iliac artery stents does not have the dismal outcomes, which our original bias would have led us to believe. 24/41/112803