Aortoiliac Disease Research Articles

Mid-Term Outcomes of the Iliac Branch Endoprosthesis with Standardized Combinations of Bridging Stent-Grafts for Endovascular Treatment of Aortoiliac Disease with or Without Co-existing Hypogastric Aneurysms (The HYPROTECT Study).

To evaluate retrospectively the 2-year outcomes of the Gore Excluder Iliac Branch Endoprosthesis (IBE) in patients with and without coexisting hypogastric artery (HA) aneurysms in a large contemporary multicentric European experience using dedicated bridging devices. The study included all consecutive patients treated at participating institutions with the Gore Excluder IBE device who received a covered stent (i.e., stent-graft) from the same manufacturer. Technical success was defined as deployment of endografts with complete exclusion of the aneurysm(s), patency of target vessels, and absence of type 1 and 3 endoleak. Assessment of follow-up outcomes included freedom from HA branch instability defined as the composite cumulative endpoint of any HA branch-related complication. A total of 437 patients were included for analysis from 22 European vascular surgery centers. Patients were categorized into two subgroups: subgroup A (n = 269) if they did not have concomitant hypogastric aneurysms, otherwise they were categorized into subgroup B (n = 168). Finally, 78 (18%) had bilateral IBE with a total of 515 IBE included in the study. Balloon expandable stents were deployed in 19 (6.3%) subgroup A patients compared with 46 (21.7%,) in subgroup B, p < .001. The two-year estimate for freedom of HA branch instability was significantly higher for patients in group A as compared with patients in group B (94% vs. 90%, p = .045). At univariate regression, the number of stent-grafts used was associated with higher risk of iliac branch instability (p = .021), while in multivariate regression for the use of more than 2 bridging stent-grafts the risk of instability increased by 2.35 times. This large contemporary European multicentric experience with the use of the Gore Excluder IBE in patients with or without associated HA aneurysms shows satisfactory mid-term outcomes when the device is used in conjunction with both self-expandable and balloon-expanding stent-grafts from the same manufacturer. Although primary patency of the iliac branch was as high as 90%, caution and strict follow-up must be exercised when multiple bridging stent-grafts are used over longer distances.

Bifurcated Endografts for the Treatment of Aortoiliac Disease a Systematic Review and Individual Patient Data (IPD) Meta-Analysis.

This review aimed to assess the efficacy and safety of bifurcated endografts in the treatment of aortoiliac disease (AOID). A systematic search on PubMed, Scopus, and Web of Science was performed. The primary endpoint was primary patency, whereas secondary endpoints included reintervention, technical, clinical success, and overall postoperative complications. Ten studies with a total of 365 patients were included in this review. Most included studies used the AFX unibody endograft, one study the Excluder endograft, and one the Powerlink endograft. The majority of included patients displayed TransAtlantic InterSociety Consensus (TASC) D aortoiliac lesions (56.1% 205/365). The pooled primary patency estimates at 12, 24, and 36 months were 93.93% (95% confidence interval [CI]: 87.7-100), 91.46% (95% CI: 84.6-98.8), and 90.25% (95% CI: 82.6-98.6), respectively. The mean primary patency time was 85.74 months (95% CI: 71.99-86.88). The pooled freedom from reintervention estimates at 12, 24, and 36 months were 91.94% (95% CI: 81.4-100), 91.03% (95% CI: 79.8-100), and 91.03% (95% CI: 79.8-100), respectively. The pooled estimates of major complications (rupture, graft thrombosis, amputation) were 11.12% (95% CI, 0.05%-3.03%), 3.76% (0.32%-9.45%), and 0.38% (0%-2.59%), whereas the pooled estimates for minor complications (hematoma, groin infection, dissection) and overall mortality were 5.27% (95% CI, 1.11%-11.38%), 6.93% (95% CI, 2.94%-12.16%), 2.19% (95% CI, 0.06%-6.14%), and1.57% (95% CI, 0.13-3.97), respectively. Technical and clinical success estimates were 99.92% (95% CI: 98.86%-100%) and 99.47% (95% CI: 94.92%-100%), respectively. The application of bifurcated endografts may present a safe and viable option in the treatment of AOID, with preliminary results indicating promising primary patency outcomes. However, the definitive assessment of their efficacy and safety will be better determined through long-term follow-up studies and high-quality randomized controlled trials, which are essential to substantiate these initial findings. Bifurcated endograft application may be a safe and viable alternative for high-risk patients with complex AOID TASC C and D lesions with encouraging primary patency outcomes potentially comparable to those of open surgery. Non-negligible postoperative complication rates were also noted. High-quality randomized controlled trials and studies comparing CERAB, kissing stenting, and the use bifurcated endografts for the treatment of AOID is necessary to draw more definite conclusions.

The Long-Term Results of Covered Endovascular Aortic Bifurcation Repair in Complex Aortoiliac Disease: A Two-Year Follow-Up.

Background: We aimed to investigate the two-year outcomes of covered endovascular reconstruction (CERAB) of the aortic bifurcation in patients with complex aortoiliac occlusive dis ease. Methods: This study was prospectively initiated, with data retrospectively collected from 40 patients categorized as TASC II B, C, and D based on computed tomography angiography (CTA) findings. All patients underwent the CERAB procedure. We assessed the procedural outcomes, including clinical and symptomatic improvements, as well as patency rates over a two-year follow-up period. Results: A total of 40 patients (33 males and 7 females) with aorto-occlusive disease were treated using the CERAB procedure and included in this observational study. The technical success rate was 100% across all procedures. At 36 months, the overall primary patency, assisted primary patency, and secondary patency rates were 85%, 90%, and 92.5%, respectively. Conclusions: The two-year results of this study suggest that CERAB offers patency rates comparable to those reported in other studies for complex aorto-occlusive bifurcation diseases. The procedure showed favorable patency rates, particularly for more advanced TASC II B, C, and D lesions.

Intravascular Lithotripsy and Aortic Bare-Metal Stenting: A Low-Profile Solution for the Treatment of Heavily Calcified Aorto-Iliac Disease.

To present a novel technique for the treatment of heavily calcified aorto-iliac disease using intravascular lithotripsy (IVL) and self-expanding bare-metal stents (BMS). We present our experience with 4 cases of calcified aorto-iliac disease that were treated with IVL as vessel preparation followed by BMS deployment. Intravascular lithotripsy was performed using a 7-mm or 8-mm Shockwave catheter from 1 access and a non-compliant balloon introduced from the second access in a "hugging-balloon" configuration. Afterward, a self-expandable BMS is deployed in the infrarenal aorta and additional bare-metal balloon-mounted stents are deployed in the iliac arteries as needed. This technique provides a low-profile solution with only 6- and 7-French introducers, preservation of the collateral circulation while also preserving the option for an up-and-over approach in the future. Technical success was achieved in all cases and no periprocedural complications were observed. Intravascular lithotripsy in combination with BMS for the infrarenal aorta and the aortic bifurcation seems to be a safe and effective low-profile treatment option for heavily calcified lesions. Large-scale studies with long-term follow-up are needed to validate our positive early results. Endovascular treatment of heavily calcified aortoiliac disease poses significant challenges, including the risk of rupture and dissection. The proposed technique uses intravascular lithotripsy and bare-metal stenting of the aortic bifurcation and represents a low-profile solution that preserves collaterals and potentially reduces the risk of dissection with IVL vessel preparation.

Multicenter CT Image-Based Anatomic Assessment of Patients with Aortoiliac Aneurysm Undergoing Endovascular Repair with Iliac Branch Devices

ObjectiveThe Global Iliac Branch Study (NCT05607277) is an international, multicenter, retrospective cohort study of anatomic predictors of adverse iliac events (AIE) in aortoiliac aneurysms treated with iliac branch devices (IBDs). MethodsPatients with pre- and post-IBD CT imaging were included. We measured arterial diameters, stenosis, calcification, bifurcation angles, and tortuosity indices using a standardized, validated protocol. A composite of ipsilateral AIE was defined, a priori, as occlusion, type I or III endoleak, device constriction, or clinical event requiring reintervention. Paired t-test compared tortuosity indices and splay angles pre- and post-treatment for all IBDs and by device material (stainless steel and nitinol). Two-sample t-test compared anatomical changes from pre- to post-treatment by device material. Logistic regression assessed associations between AIE and anatomic measurements. Analysis was performed by IBD. ResultsWe analyzed 297 patients (286 males, 11 females) with 331 IBDs (227 stainless steel, 104 nitinol). Median clinical follow-up was 3.8 years. Iliac anatomy was significantly straightened with all IBD treatment, though stainless steel IBDs had a greater reduction in total iliac artery tortuosity index and aortic splay angle compared to nitinol IBDs (absolute reduction -.20 [-.22 to -.18] versus -.09 [-.12 to -.06], P<.0001 and -19.6° [-22.4° to -16.9°] versus -11.2° [-15.3° to -7.0°], P=.001, respectively). There were 54 AIEs in 44 IBDs in 42 patients (AIE in 13.3% of IBD systems), requiring 35 reinterventions (median time to event 41 days; median time to reintervention 153 days). There were 18 endoleaks, 29 occlusions, and five device constrictions. There were no strong associations between anatomic measurements and AIE overall, though internal iliac diameter was inversely associated with AIE in nitinol devices (nAIE,nitinol=8). ConclusionsPurpose-built iliac branch devices effectively treat aortoiliac disease, including that with tortuous anatomy, with a high patency rate (91.5%) and low reintervention rate (9.1%) at four years. Anatomic predictors of AIE are limited.

Quality of Life Outcomes Following Aortofemoral and Iliofemoral Bypass Surgery in Patients With Peripheral Arterial Disease: A Two-Year Follow-Up Study.

Peripheral arterial disease is a circulatory disorder characterized by reduced blood flow to the extremities, predominantly affecting the lower limbs. This study aims to evaluate the impact of aortofemoral and iliofemoral bypass surgeries on patients' quality of life two years post operation and identify predictors of quality-of-life improvements. This cross-sectional study included adult patients with aortoiliac disease who underwent bypass surgery (aortofemoral or iliofemoral) at East Jeddah General Hospital from January 2020 to December 2022. Quality of life was assessed using the Arabic version of the Short Form Health Survey 12 (SF-12) preoperatively and two years postoperatively. Data on sociodemographic factors (age, sex, education, income) and medical factors (smoking, BMI, comorbidities) were collected. Statistical analyses included descriptive statistics, t-tests, one-way ANOVA, and regression analyses using IBM SPSS version 25.0 (IBM Corp., Armonk, NY). The study included 275 patients. Significant improvements in both physical and mental SF-12 scores were observed postoperatively across all patient groups (P < 0.001). Older age, unemployment, and lower income were associated with lower SF-12 scores. Males had higher postoperative mental scores (P = 0.036). Higher BMI and smoking pack-years negatively correlated with SF-12 scores. Patients with comorbidities had significantly lower preoperative and postoperative SF-12 scores (P < 0.05)but showed significant improvements postoperatively (P < 0.001). Aortofemoral and iliofemoral bypass surgeries significantly improve the quality of life in peripheral arterial disease patients two years post operation. Key predictors of lower quality of life include older age, unemployment, lower income, high BMI, smoking, and comorbidities. Targeted interventions, such as smoking cessation programs, weight management, and comprehensive medical care, are essential for optimizing postoperative outcomes and enhancing patients' physical and mental well-being.

Intravascular Ultrasound Use is Associated with Improved Patency in Lower Extremity Peripheral Arterial Interventions

ObjectivesIntravascular ultrasound (IVUS) facilitates detailed visualization of endoluminal anatomy not adequately appreciated on conventional angiography. However, it is unclear if IVUS use improves clinical outcomes of peripheral vascular interventions (PVI) for peripheral arterial disease (PAD). This study aimed to evaluate the impact of IVUS on 1-year outcomes of PVI in the vascular quality initiative (VQI). MethodsThe VQI-PVI modules were reviewed (2016-2020). All patients with available one-year follow up after lower extremity PVI were included and grouped as IVUS-PVI or non-IVUS PVI based on use of IVUS. Propensity matching (1:1) was performed using demographics and comorbidities. One-year major amputation and patency rates were compared. A generalized estimating equation (GEE) model was used to identify predictors of 1-year outcomes. Subgroup analysis based on Trans-Atlantic Inter-Society Consensus (TASC) classification, treatment length and treatment modalities were performed using same modeling approaches. ResultsThere were 56,633 procedures (non-IVUS PVI=55,302 vs IVUS-PVI=1,331) in 44,042 patients. Propensity matching yielded a total cohort of 1,854 patients matched (1:1), with no baseline differences. LER for claudication was performed in 60.4%, while one-third (33.9%) had chronic limb threatening ischemia (CLTI). IVUS was more commonly used for lesions >15cm in length (46.6% vs 43.3%) and for aortoiliac disease (31.8% vs 27.2%). Rates of atherectomy and stenting were significantly higher with IVUS-PVI (21.1% vs 16.8%), while balloon angioplasty was less common (13.5% vs 24.4%). One-year patency was better with IVUS-PVI (97.7% vs 95.2%, p=0.004). On subgroup analysis, IVUS (OR 2.20, 95% CI 1.29- 3.75) was associated with improved patency in CLTI patients, TASC C or D lesions, and treatment length >15cm. Adjunctive IVUS use during PVI did not significantly impact 1-year amputation (OR 1.7, 95%CI 0.78-3.91). On multivariable regression, adjunctive use of IVUS (OR 2.46 95%CI 1.43-4.25) and aortoiliac interventions (OR 2.91, 95%CI 1.09-7.75) were independent predictors of patency. Treatment modalities such as atherectomy, stenting or balloon angioplasty did not significantly impact patency at 1-year. ConclusionIVUS during lower extremity PVI is associated with improved 1-year patency, when compared to angiography alone. Certain subgroups, such as CLTI patients, lesions>15cm, and TASC C or D lesions might benefit from adjunctive use of IVUS.

MANAGEMENT OF AORTIC OCCLUSION SYNDROME ASSOCIATED TO GRAVES DISEASE

Background :Leriche syndrome or aortoiliac occlusion disease is caused by atherosclerosis and manifests as a constellation of symptoms that include claudication, erectile dysfunction, and the notable absence of femoral pulses. Graves disease (also known as Basedow) is an autoimmune disorder characterized by excessive thyroid hormone production, leading to hyperthyroidism. It often results in symptoms such as weight loss, rapid heart rate, tremors, and an enlarged thyroid gland (goiter).We present a case study detailing a singular occurrence of Leriche syndrome in a patient concurrently diagnosed with Graves disease, emphasizing the intricate nuances encountered in anesthesia management across both surgical procedures. Case presentation: A 53-year-old North African male with history of smoking presented to the ED with critical limb ischemia. The patient exhibited normal vital signs, except for a sinus tachycardia of 140 beats per minute. Initial blood laboratory tests yielded no abnormalities. However, abdominopelvic computed tomography angiography (CTA) revealed an abdominal aortic aneurysm measuring 46mm in diameter and extending over 107mm. This aneurysm was found to be partially thrombosed above the renal arteries, with complete thrombosis noted at the infrarenal level, extending bilaterally to the iliac arteries. The presence of collateral blood vessels supported the diagnosis of Leriche syndrome. Additionally, further investigation into the sinus tachycardia revealed the patients diagnosis of Graves disease, complicating the vascular surgery. After collegial discussion, a two-stage surgical approach was decided upon. Initially, the patient underwent medical treatment using a rapid thyroid hormone blocking protocol to manage the signs of hyperthyroidism. Following achievement of biochemical and clinical euthyroidism, characterized by stable thyroid hormone levels, the first surgery, total thyroidectomy, was performed. Subsequently, a few days later, the patient underwent a bypass surgery. The postoperative course was marked by successful bypass graft surgery, resulting in improved limb function and absence of further complications. The patient was discharged home 10 days after the second surgery. Conclusion : In this case, the challenge lay in managing both conditions while ensuring controlled heart rate and blood pressure to prevent aneurysm rupture, and concurrently administering anticoagulant therapy to prevent thrombus extension. Our findings suggest that in comparable cases, emphasis on thorough physical examination and medical history is crucial, and interdisciplinary collaboration between different specialties enhances patient survival.

Early and midterm results of covered balloon-expandable stents (VBX-Gore) for endovascular treatment of chronic aorto-iliac occlusion.

Endovascular treatment is nowadays accepted as first-line treatment for most patients with aorto-iliac obstructive disease (AIOD), including those with Trans-Atlantic Inter-Society Consensus II (TASC-II) lesion types C and D. Aim of the study was to evaluate the role of Viabahn VBX (W. L. Gore and Associates, Flagstaff, AZ, USA), in patients with chronic occlusive aorto-iliac disease (ChO). A retrospective review of patients undergone elective endovascular repair with VBX (W. L. Gore and Associates) for ChO at five referral vascular institutions in Italy from 2018 to 2022 was conducted. Primary endpoints were technical success and the incidence of any early and midterm procedure-related reintervention. Secondary endpoints were clinical success, primary and secondary patency. Among 89 included patients, technical success was obtained in 87 patients (97.8%). Postoperative complication requiring early surgical reintervention was necessary in 5 (6%), all but one for arterial bleeding. Clinical improvement of at least 3 classes was observed in 49 (55%). After a mean follow-up of 24.1 months ±14.1, primary patency and freedom from any procedure-related reintervention at 12, 24 and 36 months was 83.0% and 94.8%, 80.0% and 91.5%, 77.9% and 89.3%, respectively. Secondary patency was 100%. TASC-II D lesion (OR=3.67, 95% CI: 1.1289-11.9823, P=0.03) and Grade III iliac calcification (OR=3.41, 95% CI: 1.0944-10.6428, P=0.03) were identified as independent predictors for procedure-related reintervention. Use of VBX (W. L. Gore and Associates) in ChO was safe and effective with low rate of stenosis/occlusion in the early and mid-term follow-up. TASC-II D and Grade III calcifications resulted as independent predictors for procedure-related reintervention.

Covered endovascular reconstruction of the aortic bifurcation: A versatile technique with many potential applications.

We present our experience with using the bifurcated covered endovascular reconstruction technique in two unusual conditions. One patient with a traumatic "seat belt" aortic injury and a second patient with a bleeding aorto-enteric fistula were successfully treated with the CERAB technique. We discuss potential benefits of the technique outside the usual pattern of chronic atherosclerotic aortoiliac disease.

Combination of BeGraft and Solaris Stent Grafts for the Covered Endovascular Reconstruction of Aortic Bifurcation-BS-CERAB Technique.

Background: This study examines the impact of the use of the combination of BeGraft and Solaris stent grafts on the outcomes during the covered endovascular reconstruction of aortic bifurcation (BS-CERAB) technique and extension to the iliac arteries. Methods: Consecutive patients with aortoiliac occlusive disease who underwent endovascular treatment using BS-CERAB between January 2020 and December 2023 were included. Patient demographics, symptoms, lesion characteristics, and procedural and follow-up details were collected and analyzed. Perioperative complications and reinterventions were also identified. Results: A total of 42 patients met the inclusion criteria (32 men, 76.2%, median age 72 years, range 59-85). Indications for treatment were intermittent claudication (42.9%) and critical limb ischemia (57.1%). Procedure success was achieved in all cases. The median patient follow-up time was 14 months (1-36). One patient died at a 10-month follow-up due to lung cancer. The mean pre-operative ABI increased from 0.37 ± 0.19 before intervention to 0.71 ± 1.23 post-operatively at 12 months (p = 0.037). The estimated primary patency rates at 3, 6, and 12 months were 90.5%, 85.7%, and 81.0% and primary assisted patency rates were 90.5%, 90.5%, and 85.7%, respectively. Secondary patency was 95.2% at 3 and 6 months and 90.5% at a 12-month follow-up. Active cancer (p = 0.023, OR 2.12 95%CI 1.14-3.25) was a risk factor for restenosis. Conclusions: This mid-term experience shows that the CERAB technique using the combination of BeGraft and Solaris stents grafts, for the endovascular treatment of severe aortoiliac atherosclerotic disease, may allow an effective reconstruction of the aortic bifurcation and iliac arteries related to high-patency and lower-reintervention rates.

Role of intravascular ultrasound for the technical assessment of endovascular reconstruction of the aortic bifurcation

ObjectiveThe aim of this study was to evaluate the role of intravascular ultrasound (IVUS) for the technical assessment of kissing stents (KSs) and covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac obstructive disease involving the aortic bifurcation. MethodsWe conducted a single-center retrospective review of patients undergoing endovascular treatment of severe aorto-iliac obstructive disease (2019-2023). IVUS was performed in patients treated by KSs or CERAB according to preoperative indications, in cases of moderate/severe calcifications, mural thrombus, total occlusions, and lesion extension towards the proximity of renal or hypogastric arteries. Indications for IVUS-guided intraoperative revisions were residual stenosis or compression >30%, incomplete stent-to-wall apposition, or flow-limiting dissection at the landing site. Follow-up assessment was performed at 6 and 12 months, and then yearly. Thirty-day outcomes and 2-year patency rates were evaluated. Logistic regression was used to identify factors associated with significant technical defects detected by IVUS needing intraoperative revision. ResultsIVUS was used for the technical assessment of 102 patients treated by KSs (n = 57; 56%) or CERAB (n = 45; 44%) presenting with severe intermittent claudication (39%), rest pain (39%), or ischemic tissue loss (25%). Twenty-nine significant technical defects were identified by IVUS in 25 patients (25%) who then had successful intraoperative correction by additional ballooning (n = 23; 80%) or stenting (n = 6; 20%). Patients with a severely calcified chronic total occlusion (odds ratio, 1.85; 95% confidence interval, 1.01-5.27; P = .044) or severely calcified narrow aortic bifurcation with <12 mm diameter (odds ratio, 2.34; 95% confidence interval, 1.10-8.64; P = .032) were at increased risk for IVUS-guided intraoperative revision. There were no postoperative deaths and no major adverse events. Two-year primary patency was 100%. ConclusionsIVUS was used for the technical assessment of KSs/CERAB in a selected cohort of patients with severe aorto-iliac obstructive disease. This allowed the identification and intraoperative correction of a significant technical defect not detected by completion angiogram in one-quarter of patients, achieving optimal 2-year results. IVUS assessment of KSs/CERAB may be considered especially in patients with a calcified total occlusion or narrow aortic bifurcation.

Factors associated with 90-day reintervention following lower extremity revascularization

ObjectivePeripheral artery disease (PAD) represents a high-volume, high-cost burden on the health care system. The Centers for Medicare and Medicaid Services has developed the Bundled Payments for Care Improvement-Advanced program, in which a single payment is provided for all services administered in a postsurgical 90-day episode of care. Factors associated with 30- and 90-day reinterventions after PAD interventions would represent useful data for both payors and stake holders. MethodsWe conducted a national cohort study of adults 65 years and older in the Vascular Quality Initiative and Centers for Medicare and Medicaid Services-linked dataset who underwent an open, endovascular, or hybrid revascularization procedure for PAD between January 1, 2010, and December 31, 2018. Procedures for acute limb ischemia and aneurysms were excluded. The primary outcome was 90-day reintervention. Reintervention at 30 days was a secondary outcome. Covariates of interest included demographics, comorbidities, and patient- and facility-level characteristics. Multivariable Cox regression was used to determine the association between patient- and facility-level characteristics and the risk of 30- and 90-day reinterventions. ResultsAmong 42,429 patients (71.3% endovascular, 23.3% open, and 5.4% hybrid), median age was 74 years (interquartile range, 69-80 years), 57.9% were male, and 84.3% were White. Chronic limb-threatening ischemia was the operative indication in 40.4% of the procedures. Overall, 42.8% were completed in the outpatient setting (40.3% outpatient, 2.5% office-based lab). Over 70% of procedures for chronic limb-threatening ischemia were completed as inpatient, whereas 60% of the claudication interventions were done as outpatient. The 90-day reintervention rate was 14.5%, and the 30-day reintervention rate was 5.5%. Compared with inpatient procedures, PAD interventions completed in the outpatient or office-based lab setting had significantly higher 90- and 30-day reintervention rates (reference, inpatient; outpatient 90-day reintervention: hazard ratio [HR], 1.41; 95% confidence interval [CI] 1.25-1.60; outpatient 30-day reintervention: HR, 1.90; 95% CI, 1.62-2.24; office-based lab 90-day reintervention: HR, 2.09; 95% CI, 1.82-2.41; office-based lab 30-day reintervention: HR, 3.54; 95% CI, 3.17-3.94). Open and hybrid approaches demonstrated lower risk of reintervention compared with endovascular procedures at 30 and 90 days and, compared with aortoiliac disease, all other anatomic segments of disease were associated with higher 90-day reintervention, but no difference was noted at 30 days. ConclusionsAlthough outpatient PAD interventions may be convenient for patients and providers, the outpatient setting is associated with a significant risk of subsequent reintervention. Additional work is needed to understand how to improve the longevity of outpatient PAD interventions.

Mid-term Results of Endovascular Reconstruction of Aortic Bifurcation Using COVERA Stent Graft.

This article aims to evaluate the short-term and mid-term performance of a self-expanding covered stent (COVERA Plus, Bard Tempe, Arizona) during the treatment of Trans-Atlantic Inter-Society Consensus (TASC) C/D aortoiliac obstructive lesions involving the aortic bifurcation. A single-center retrospective review of all patients who underwent endovascular reconstruction of the aortoiliac bifurcation for obstructive disease, with the use of Covera, from January 2018 to March 2023. All patients received a postoperative CTA (computed tomography angiography) scan within 1 month from the intervention. Precision of deployment, stent conformation, and stent symmetry were evaluated at the arterial phase of the CTA. Early outcomes were technical success and freedom from open aortic reintervention and/or mortality. Late outcomes were primary and assisted primary patency rates and freedom from reintervention. During the study period, 35 patients underwent primary endovascular treatment of obstructive lesions involving the aortic bifurcation with parallel COVERA stents. Aortoiliac lesions were classified as TASC-IIC in 23 (65.7%) patients and TASC D in 12 (34.2%). Median follow-up was 49 months (interquartile [IQR]: 18-60). Overall survival was 97.1% (95% confidence interval [CI]=91-100) at 60 months. During follow-up, there were one early stent stenosis, treated with an angioplasty and stent relining with an estimated primary patency at 60 months of 97.1% (95% CI=94-100) and a primary-assisted patency of 100%. Estimated freedom from all types of reinterventions at 60 months was 94.3% (95% CI=89-99.3). The new self-expanding covered Bard COVERA Plus stent used for endovascular treatment of TASC C/D aorto iliac disease proved to be safe and feasible with high technical procedural success rates. Comparison with other types of stents is necessary to further assess the role of the COVERA Plus stent in aortic bifurcation repair. This study investigates the safety and feasibility of the new self-expanding covered Bard Covera Plus stent used for endovascular treatment of TASC C/D aorto iliac disease. The retrospective analysis of 35 patients highlights high technical success and primary patency rate at 60 months. The geometric analysis also helped to underline how this stent can be used precisely in particular conditions. These findings suggest the need for further research to compare COVERA with other types of stents in aortic bifurcation repair.

Outcomes of Surgical Revascularization in Trans-Atlantic Society Consensus (TASC II) Type C &amp; D Aortoiliac Occlusive Disease

Introduction: Aortoiliac occlusive disease is a disabling illness. This study was conducted on the patients of Trans-Atlantic Society Consensus (TASC II) type C &amp; D aortoiliac occlusive disease. Open surgical revascularization in the form of aortofemoral and aorto-bifemoral bypass grafting was done and the demography of patients of AIOD, the efficacy and outcomes of open surgical bypass in the patients of TASC II, type C &amp; D aortoiliac occlusive disease was studied. Methods: in this study, total of 52 patients were revascularized and were observed for various parameters thoroughly throughout the course of diagnosis, preoperative, intra-operative and postoperative phase and until 6 months of follow-up. The demographics, clinical characteristics of the patients, co-morbid conditions, type of aorto-iliac occlusive disease (AIOD), the surgical procedure conducted and the outcomes of surgery in terms of limb salvageability, healing of ulcer, relief of claudication and graft patency were observed. Results: 50 (96.16%) out of 52 patients were males, with a mean age of presentation 55.01 + 8.58 years. 47 (90.38%) were smokers, 43 (82.69%) had hypertension, 17 (32.69%) had diabetes, 11 (21.15%) had CAD, 12 (23.07%) had COPD, 22 (42.30%) had type C and 30 (57.69%) patients had type D disease. Aorto-bifemoral bypass grafting was done in 42 (80.76%) . Mean duration of ICU stay was 1.9 days, 6 (11.53%) patients expired postoperatively. The graft patency and limb salvageability were 100% and 96.15% respectively during 1st, 3rd and 6th months of follow-up with complete healing of ulcers in 21 (91.30%) patients by the end of 6 months. Conclusion: Surgical revascularization is an important, high yielding, life changing intervention which serves as a boon for the patients with extensive or advanced aortoiliac disease. The surgery has excellent outcomes in terms of graft patency as well as limb salvageability.

Comparing endovascular and open reconstruction for TASC-II D aortoiliac disease: a propensity score analysis

Background: Aortoiliac disease management remains a subject of ongoing debate, with a shift in focus toward endovascular techniques, even in complex cases. This study aimed to evaluate and compare the safety and results of open surgery with endovascular surgery for treating TASC-II D aortoiliac lesions. Methods: From January 2013 to February 2021, the clinical data of 89 patients revascularized with symptomatic TASC ΙΙ D AID were analyzed in a prospective cohort study. The patients were divided into two groups: open repair (61 patients) and endovascular treatment (28 patients). Baseline characteristics, preoperative and postoperative imaging, operation procedure reports and follow-up were reviewed and analyzed. Kaplan-Meier survival analysis, multivariate Cox regression, and a Propensity Score Matching (PSM) analysis were used to evaluate the relevance between risk factors and surgical technique. Results: Open repair had a higher technical success rate (100% vs. 73.7%, p=0.01). 30-day major adverse cardiovascular (MACE) and limb (MALE) events showed no differences between both groups (PSM: 1 (4.8%) vs. 0, p=0.462 and 1 (4.8%) vs. 2 (13.3), p=0.235, respectively). Cox multivariable regression proportional hazard ratio showed no significant differences in terms of MALE between open and endovascular revascularization at 36 months (hazard ratio, HR 1.31 95% CI 0.56-3.06, p=0.54), even after PSM (HR 1.63 95% CI 0.58-4.55, p=0.35). Moreover, MACE and all-cause mortality also didn´t show a statistically significant difference between groups (HR 0.77 95% CI 0.22-2.64, p=0.67 and HR 0.97 95% CI 0.27-3.46, p=0.96). Conclusions: Open and endovascular techniques are safe and effective treatments for complex AIOD. It is expected to have a higher technical success rate with open repair; however, there are no significant differences in MACE or MALE between these two approaches.

Hybrid Pelvic Revascularization in Complex Aortoiliac Aneurysm Repair

Revascularization of complex pelvic vascular anatomy presents an ongoing clinical challenge when treating aortoiliac disease. As vascular surgeons continue to intervene upon increasingly complex aortoiliac pathology, the role of pelvic revascularization is important for the preservation of pelvic organ function and prevention of devastating spinal cord ischemia. In this study we describe the indications, techniques, and clinical outcomes of a novel hybrid pelvic revascularization repair that focuses on optimizing revascularization while limiting pelvic surgical dissection during the management of complex aortic pathology in patients physiologically or anatomically unsuitable for traditional pelvic revascularization techniques.

Comparing the Safety and Feasibility of Endovascular Therapy via Transradial and Transfemoral Approaches in Patients with Aortoiliac Occlusive Disease: A Propensity Score-Matched Analysis of the Nationwide Registry.

Our objective was to evaluate the feasibility of performing endovascular therapy (EVT) for aortoiliac artery disease using transradial approach (TRA) as compared to transfemoral approach (TFA). We analyzed 9671 cases with symptomatic lower extremity artery disease due to aortoiliac occlusive disease (AIOD) treated using EVT from a Japanese Nationwide EVT Registry between January and December 2021. We compared the baseline characteristics, procedural information, and 30-day outcomes of patients who received EVT only via TRA (n=863 [16.9%]) and those only via TFA (n=4255 [83.1%]) by using propensity score (PS) matching, after excluding those who required regular dialysis, those who underwent hybrid surgeries, and those who received EVT through 2 or more approach sites. After matching, the final study population consisted of 862 matched patients with similar baseline characteristics in each group. Technical success rate was comparable between the 2 groups (99.3% vs. 99.3%, p>0.99). No significant differences were observed with respect to the composite of all-cause death within 48 hours after EVT and post-procedural complications within 30 days, including severe bleeding that required transfusion, revascularization procedures, urgent surgeries, cerebral infarction, and major limb amputation (0.2% vs. 0.7%, p=0.29). Transradial approach was associated with shorter operation time (85 vs. 90 minutes, p=0.016), but longer fluoroscopy time (26 vs. 20 minutes, p<0.001) and higher contrast agent volume (80 vs. 75 mL, p<0.001). After PS matching, TRA showed the comparable rates of successful EVT and 30-day complications in patients with AIOD compared to TFA. Transradial approach was found to be safe and be a viable alternative of TFA for the treatment of AIOD. The efficacy of transradial approach (TRA) is established in percutaneous coronary intervention; however, its safety and feasibility are unclear in endovascular therapy (EVT). We analyzed 9,671 cases with symptomatic aortoiliac occlusive disease treated using EVT from a Nationwide Registry to compare the 30-day outcomes of those who received EVT only via TRA (n = 863 [16.9%]and those only via TFA (n=4,255 [83.1%]) by using propensity score matching. Technical success rate (99.3% vs. 99.3%, p > 0.99) and 30-day complications (0.2% vs. 0.7%, p = 0.29) were comparable between the two groups. EVT via TRA could be performed safely.

Gender disparities in patients with aortoiliac disease requiring open operative intervention

ObjectivePeripheral artery disease is known to affect males and females in different proportions. Disparate surgical outcomes have been quantified after endovascular aortic aneurysm repair, arteriovenous fistula creation, and treatment of critical limb ischemia. The aim of this study is to objectively quantify the sex differences in outcomes in patients undergoing open surgical intervention for aortoiliac occlusive disease. MethodsPatients were identified in the aortoiliac occlusive disease Vascular Quality Initiative database who underwent aorto-bifemoral bypass or aortic thromboendarterectomy as determined by Current Procedural Terminology codes between 2012 and 2019. Patients with a minimum of 1-year follow-up were included. Risk differences (RDs) by sex were calculated using a binomial regression model in 30-day and 1-year incidence of mortality and limb salvage. Additionally, incidence of surgical complications including prolonged length of stay (>10 days), reoperation, and change in renal function (>0.5 mg/dl rise from baseline), were recorded. Inverse probability weighting was used to standardize demographic and medical history characteristics. Multivariate logistic regression models were employed to conduct analyses of the before mentioned clinical outcomes, controlling for known confounders. ResultsOf 16,218 eligible patients from the VQI data during the study period, 6538 (40.3%) were female. The mean age, body mass index, and race were not statistically different between sexes. Although there was no statistically significant difference detected in mortality between males and females at 30 days postoperatively, females had an increased crude 1-year mortality with an RD of 0.014 (95% confidence interval, 0.01-0.02; P value < .001. Males had a higher rate of a postoperative change in renal function with an RD of −0.02 (95% confidence interval, −0.03 to −0.01; P < .001). ConclusionsAlthough there was no sex-based mortality difference at 30 days, there was a statistically significant increase in mortality in females after open aortoiliac intervention at 1 year based on our weighted model. Male patients are statistically significantly more likely to have a decline in renal function after their procedures when compared with females. Postoperative complications including prolonged hospital stay, reoperation, and wound disruption were similar among the sexes, as was limb preservation rates at 1 year. Further studies should focus on elucidating the underlying factors contributing to sex-based differences in clinical outcomes following aortoiliac interventions.

Adherence to Society for Vascular Surgery Guidelines for Claudication in the Society for Vascular Surgery Vascular Quality Initiative

Current Society for Vascular Surgery (SVS) guidelines recommend 51 specific factors related to the management of intermittent claudication as quality measures. It was the objective of this study to assess rates of adherence to these guidelines for patients treated with suprainguinal or infrainguinal bypass or percutaneous vascular intervention and to determine if this was associated with a difference in the periprocedural outcomes. All patients from the SVS Vascular Quality Initiative (VQI) undergoing infrainguinal bypass (INFRA), suprainguinal bypass (SUPRA), and percutaneous vascular intervention (PVI) for claudication from 2018 were included. Nonelective procedures for other than chronic atherosclerotic disease were excluded. The rates of adherence to each assessable guideline were evaluated. For outcomes analysis, individuals were classified as “adherent” to the guidelines vs not and compared. Of the 51 SVS recommendations, 12 could be evaluated using VQI registries; these included first-line ankle-brachial index, smoking cessation, statin therapy, antiplatelet therapy with aspirin, optimal medical therapy after intervention, anatomic imaging studies before intervention, optimizing diabetes control, Plavix as second-line antiplatelet, adjunct stenting in intermediate superficial femoral artery lesions, annual follow-up, covered stents for the treatment of aortoiliac disease, and no recommended endovascular treatment for isolated infrapopliteal disease. The rates of overall “adherence” were 38.2% for INFRA, 17.1% for SUPRA, and 32.2% for PVI. There were a surprising number of isolated tibial (n = 1431, 3.1%) and pedal (n = 12, 0.03%) endovascular interventions performed for claudication. There were 784 tibial bypasses (19.3%), 30 (0.7%) at the ankle, 2 of which were tarsal/plantar bypasses for claudication. It appears that for the most part, there do not seem to be important clinical differences in outcomes based on the study definition of adherence for all outcomes assessed. Among factors such as survival (Fig 1), time to amputation (Fig 2), primary patency (Fig 3), and time to reoperation/reintervention for occlusion (Fig 4) for INFRA, SUPRA, and PVI, there were no differences between individuals meeting the study definition of adherence vs those not adherent for all outcomes was assessed. Overall adherence rates to SVS guidelines for the management of intermittent claudication are low and may be an opportunity for improvement in patient outcomes. An absence of differences noted in this study may reflect unmeasured factors in patient selection or in outcomes. Adding more of the SVS recommendations for the management of intermittent claudication to the VQI registry may serve as a future focus for quality improvement projects.