Aortoiliac Disease Research Articles

The Effect of Arterial Disease Level on Outcomes of Supervised Exercise Therapy for Intermittent Claudication: A Prospective Cohort Study.

To assess whether level of arterial obstruction determines the effectiveness of SET in patients with IC. Guidelines advocate SET before invasive treatment for IC, but early revascularization remains widespread, especially in patients with aortoiliac disease. Patients were recruited from 10 Dutch centers between October 2017 and October 2018. Participants received SET first, followed by endovascular or open revascularization in case of insufficient effect. They were grouped according to level of stenosis (aortoiliac, femoropopliteal, multilevel, or rest group with no significant stenosis). Changes from baseline walking performance (maximal and functional walking distance on a treadmill test, 6-minute walk test) and vascular quality of life questionnaire-6 at 3 and 6 months were compared, after multivariate adjustment for possible confounders. Freedom from revascularization was estimated with Kaplan-Meier analysis. Some 267 patients were eligible for analysis (aortoiliac n = 70, 26%; femoropopliteal n = 115, 43%; multilevel n = 69, 26%; rest n = 13, 5%). No between group differences in walking performance or vascular quality of life questionnaire-6 were found. Mean improvement in maximal walking distance after 6 months was 439 m [99% confidence interval (CI) 297-581], 466 m (99% CI 359-574), 353 m (99% CI 210-496), and 403 m (99% CI 58-749), respectively (P = 0.40). Freedom from intervention was 73.9% for aortoiliac disease and 88.6% for femoropopliteal disease (hazard ratio 2.46, 99% CI 0.96 - 6.30, P = 0.013). Short-term effectiveness of SET for IC is not determined by the location of stenosis. Although aortoiliac disease patients improved walking performance and health-related quality of life similarly compared to other arterial disease level groups, they underwent revascularization more often.

The Effect of Arterial Disease Level on Outcomes of Supervised Exercise Therapy in Intermittent Claudication: A Prospective Cohort Study

Despite guideline recommendations advocating conservative management before invasive treatment in intermittent claudication, early revascularization remains widespread, especially in patients with favorable anatomy. The aim of this study was to compare the effectiveness of supervised exercise therapy in patients with intermittent claudication according to the location of stenosis (aortoiliac, femoropopliteal, or multilevel disease).

A Propensity Score-Matched Comparison of Polytetrafluoroethylene-Covered Stents Versus Bare-Metal Stents in the Kissing Conformation for the Treatment of Aortoiliac Arterial Obstructive Disease

The objective was to compare early and midterm outcomes of polytetrafluoroethylene-covered stents (CSs) vs bare-metal stents (BMSs) used in the kissing conformation for the treatment of aortoiliac arterial obstructive disease.

Level of disease and association with health status in patients presenting with claudication from the PORTRAIT registry

ObjectivePeripheral artery disease (PAD) has been shown to affect health status and quality of life; however, the disability associated by specific anatomic level of disease is unknown. We evaluated patients presenting with claudication by anatomic level and used the Peripheral Artery Questionnaire (PAQ), a PAD-specific validated tool, to quantify patients' symptoms, function, treatment satisfaction, and quality of life. MethodsThe Patient-centered Outcomes Related to Treatment Practices in peripheral Arterial disease: Investigating Trajectories (PORTRAIT) registry is a multicenter, international, prospective study of patients with PAD. Anatomic level of PAD was stratified as follows: aortoiliac only, femoral-popliteal only, infrapopliteal only, and multilevel disease. Health status information was collected at baseline and at 3, 6, and 12 months using the PAQ. Student t-test, χ2 test, and linear mixed effects models were examined. ResultsAnatomic data were present in 623 (48.9%) of 1275 patients: 127 aortoiliac (20.4%), 221 femoral-popliteal (35.5%), 39 infrapopliteal (6.3%), and 236 multilevel disease (37.9%). Groups were similar by sex and race. Baseline PAQ summary scores differed between lesions, with multilevel disease having the lowest (poorest) estimated PAQ summary score (P = .014). Patients with aortoiliac disease were significantly younger, were more likely to be smokers, and presented with higher ankle-brachial index (all P < .05). Almost one-fourth of patients underwent an intervention by 3 months, 83% of which were endovascular. Repeated-measures analyses demonstrated a significant association between anatomic lesion and PAQ scores over time (P = .016), even after adjustment for age, sex, work status, ankle-brachial index, smoking, history of diabetes and chronic kidney disease, and country. Multilevel disease had the lowest adjusted average PAQ summary score over time (63.1; 95% confidence interval [CI], 60.8-65.5) and was significantly lower than aortoiliac (68.1; 95% CI, 64.8-71.4; P = .02) and femoral-popliteal (68.2; 95% CI, 65.8-70.6; P = .002) but not infrapopliteal (66.2; 95% CI, 60.5-72.0; P = .32). ConclusionsOverall, patients with claudication had similar health status on presentation by level of disease, yet patients with isolated aortoiliac disease fared significantly better over time with regard to quality of life and PAQ scores. Subset analysis demonstrated that patients undergoing interventions for aortoiliac disease and multilevel disease, which were primarily endovascular procedures, appeared to improve health status more over time compared with femoral-popliteal and infrapopliteal interventions. No significant benefits were found with intervention for femoral-popliteal disease or infrapopliteal disease compared with medical management. Treatment of aortoiliac and multilevel disease for claudication should be considered by clinicians as it may represent the greatest potential benefit for improving overall health status in patients with PAD. Further studies evaluating intervention compared with medical management alone are needed to further evaluate this finding.

Racial and Gender Disparity in Aortoiliac Disease Open Revascularization Procedures

BackgroundThe impact of race and gender on surgical outcomes has been studied in infrainguinal revascularization for peripheral arterial disease. The aim of this study is to explore how race and gender affect the outcomes of suprainguinal bypass (SIB) for aortoiliac occlusive disease. Materials and methodsPatients who underwent SIB were identified from the procedure-targeted National Surgical Quality Improvement Program data set (2011-2016). Patients were stratified into four groups: nonblack males, black males (BM), nonblack females, and black females (BF). Primary outcomes were 30-d major adverse cardiac events, a composite of myocardial infarction, stroke, or death; postoperative bleeding requiring transfusion or intervention; major amputation and prolonged length of stay (>10 d). Predictors of outcomes were determined by multivariable logistic regression analysis. ResultsAbout 5044 patients were identified. BM were younger, more likely to be smokers, less likely to be on antiplatelet drug or statin, and to receive elective SIB (all P ≤ 0.01). BFs were more likely to be diabetic and functionally dependent (all P ≤ 0.02). Major adverse cardiac events were not significantly different among all groups. BM had a threefold higher risk of amputation (adjusted odds ratio [OR] [95% confidence interval (95% CI)], 3.10 [1.50-6.43]; P < 0.002). Female gender was associated with bleeding in both races, that association was more drastic in BF (OR [95% CI], 2.43 [1.63-3.60]; P < 0.0001), whereas nonblack females (OR [95% CI], 1.46 [1.19-1.80]; P < 0.0001). BF had higher odds of prolonged length of stay (OR [95% CI]: 1.62 [1.08-2.42]; P < 0.019). ConclusionsIn this large retrospective study, we demonstrated the racial and gender disparity in SIB outcomes. BM had more than threefold increase in amputation risk as compared with nonblack males. Severe bleeding risk was more than doubled in BF. Race and gender consideration is warranted in risk assessment when patients are selected for aortoiliac disease revascularization, which in turn necessitate preoperative risk modification and optimization in addition to enhancing their access to primary preventive care measures.

3:00 PM Abstract No. 42 Analysis of microchannel recanalization with orbital atherectomy in failed standard recanalization of TASC-II D aortoiliac occlusive disease

Endovascular treatment of TASC II D aorto-iliac lesions now an accepted form of revascularization. We sought to analyze the technical and clinical outcomes of microchannel recanalization and orbital atherectomy (MCOA) in TASC II D aorto-iliac lesions refractory to standard recanalization techniques. Nineteen patients from 2016-2018 with symptomatic TASC-II D aortoiliac occlusive disease (AIOD) prohibitive for open bypass underwent traditional or MCOA recanalization. In four patients, native microchannels were probed and traversed with a 0.014 wire. The atherectomy crown was tracked over wire and orbital atherectomy was initiated with the 1.25 crown starting at the lowest revolution and continued until the microchannel is sufficiently large to track a 1.2 mm balloon for angioplasty. Serial microchannel angioplasty with exchange for stiffer and/or larger profile wires and balloons was achieved until a covered stent could be safely deployed across the target lesion. Technical and clinical outcomes including lesion characteristics, survival, limb salvage, patency, and change in clinical symptoms were analyzed. Both groups had similar Rutherford scores, ABI, and presence of outflow lesions. All MCOA patients presented with long segment unilateral CIA occlusion with contralateral CIA stenosis. In MCOA cases, there were no intraoperative ruptures or dissections. There were many similar metrics and outcomes between traditional recanalization versus MOCA: procedure time (150.3 min vs. 183.0 min, P = 0.41), primary patency rate (86.7% vs. 75.0%, P = 0.53), long-term (2.5 years) clinical symptoms improvement (86.7% vs. 75.0%, P = 0.53), and median all outcome progression free survival (1919 days vs. 1928 days, P = 0.62). Short-term (30 day) clinical symptoms improvement and limb salvage rate was equal between traditional recanalization versus MCOA (100% vs. 100%, P = >0.999). Native microchannel recanalization with subsequent orbital atherectomy is an option in high-risk patients with TASC II D aorto-iliac disease who have failed traditional prodding recanalization. Further work in proper patient selection and safe utilization of atherectomy devices in the CIA is needed.

AN IMPELLA’S JOURNEY THROUGH AORTOILIAC DISEASE WITH BALLOON TRACKING

There is increasing use of Impella for high risk percutaneous interventions with or without left ventricular dysfunction. Patients with complex coronary anatomy often have aortoiliac disease. Inability to place Impella device through difficult aortoiliac anatomy may preclude the high risk procedure

Monitored Anesthesia Care Is Associated With a Decrease in Morbidity After Endovascular Angioplasty in Aortoiliac Disease

Few studies have evaluated the association between anesthesia type and outcomes after endovascular angioplasty/stents for aortoiliac occlusive disease. The aim of the present study was to evaluate the association between primary anesthesia type and postprocedural complications for endovascular angioplasty of aortoiliac occlusion. Retrospective cohort study. Multi-institutional. The study comprised 3,110 patients undergoing endovascular angioplasty of aortoiliac occlusive disease, with 1,974 and 1,136 patients who underwent monitored anesthesia care (MAC) and general anesthesia (GA), respectively. The American College of Surgeons National Surgical Quality Improvement Program database for the years 2012 to 2016 was used for the present study. None. The final analysis included 3,110 patients, 63% of whom received MAC and 37% of whom received GA. The mean age was 64 years among the GA group, of whom 57.2% were male. The mean age among that MAC group was 65 years, 55.8% of whom were male. After adjusting for demographic factors and preoperative comorbidities, there was a statistically significant lower odds of postoperative complications (ie, pulmonary complications, infection, intraoperative/postoperative transfusion, reoperation, and amputation) and shorter length of stay in the MAC group compared with the GA group (p < 0.05). Although larger observational studies and randomized controlled trials are needed to further evaluate the potential effect of MAC versus GA, MAC anesthesia should be considered for patients undergoing endovascular angioplasty for aortoiliac occlusion.

Native Microchannel Recanalization with Orbital Atherectomy as a Viable Alternative to Failed Standard Recanalization of TASC II D Aortoiliac Occlusive Disease

Endovascular treatment of Trans-Atlantic Inter-Society Consensus (TASC) II D aortoiliac lesions is now an accepted form of revascularization. We sought to demonstrate that native microchannel recanalization and orbital atherectomy is a successful recanalization method of TASC II D aortoiliac lesions refractory to standard recanalization techniques. Four consecutive patients from 2016 to 2018 with symptomatic TASC II D aortoiliac occlusive disease prohibitive for open bypass and failed traditional prodding guidewire or device recanalization technique were identified and underwent advanced native microchannel selection and subsequent orbital atherectomy (Cardiovascular Systems, Inc, St Paul, MN). Native microchannels of the calcified lesions were probed and traversed with a 0.014″ wire. The atherectomy crown was tracked over the wire, and orbital atherectomy was initiated with a 1.25mm crown starting at the lowest revolution and continued until the microchannel is sufficiently large to track a 1.2mm-balloon for angioplasty. Serial microchannel angioplasty with exchange for stiffer and/or larger profile wires and balloons was achieved until a covered stent could be safely deployed across the target lesion. The kissing stent technique was then used to recreate the aortic bifurcation. A ViperSlide lubricant solution was used in all cases per indication for use. Patients were all heparinized to maintain an activated clotting time of 250. Lesion characteristics, survival, limb salvage, patency, and change in clinical symptoms were also analyzed. All 4 patients underwent successful native microchannel recanalization and orbital atherectomy of the common iliac artery (CIA). There were no intraoperative ruptures, embolizations, or dissections. All 4 patients presented with unilateral CIA occlusion with contralateral CIA stenosis. The average occlusion lesion length of the CIA was 6.0cm. The average contralateral stenosis length was 2.3cm. The kissing stent technique was used in all patients for reconstruction of the aortic bifurcation. At 30days, all patients had improvement in pain and primary patency of 100%. Long-term follow-up at 21.6months noted continued improvement in symptoms and primary patency of 75%. The fourth patient died at 4months from lung cancer with occluded iliac stents by imaging at that time. Native microchannel recanalization with subsequent orbital atherectomy is an option in high-risk patients with TASC II D aortoiliac disease who have failed traditional recanalization techniques. Further work in proper patient selection and safe utilization of atherectomy devices in the CIA is needed.

Association between anatomical distribution of symptomatic peripheral artery disease and cerebrovascular disease.

Peripheral arterial disease is frequently associated with significant atherosclerosis of other vascular beds. The aim of the present study was to investigate a possible association between peripheral arterial disease segment-specific disease burden and cerebrovascular disease. Two-hundred and twenty-six patients with clinically symptomatic peripheral arterial disease from the prospective PureASO registry were followed up after revascularization. The breadth of peripheral arterial disease was quantified at the time patients entered the study. The segment-specific peripheral arterial disease burden was correlated to cerebrovascular disease and imaging findings during a five-year follow-up. At five years, cerebrovascular disease-free survival after lower limb revascularization was 31%. Patients with peripheral arterial disease involving the crural arteries had significantly more ischemic degenerative changes at brain imaging (p = 0.031), whereas patients with aorto-iliac and femoropopliteal segment peripheral arterial disease had more significant (>50% uni- or bilaterally) internal carotid artery stenosis compared to patients with crural peripheral arterial disease (p = 0.006). According to Cox regression analyses, crural arteries burden was associated with a significantly increased risk of mortality (adjusted HR 2.07, CI 95% 1.12-3.28, p = 0.021) and cerebrovascular events (adjusted HR 1.97, CI 95% 1.19-3.26, p = 0.008). Present results suggest that atherosclerosis burden at different lower limb artery segments is associated with defined cerebrovascular disease. This further suggests that risk factors and pathophysiological mechanisms are congruent across particular vascular beds.

Long-term efficacy of a home-based training program coupled to education for patients with intermittent claudication

There are emerging evidences of efficacy of home-based exercise programs for peripheral artery disease (PAD) patients who suffer from intermittent claudication (IC), especially when they are coupled with educational programs (HEP - EPs). We have previously reported the positive one-year results of a specific 3 months home-based exercise program combined with therapeutic education. In this work, we aimed to evaluate the long-term effect of this program (24 months) in walking distance improvement. The secondary objective of the study was to evaluate the long-term results of our program for patients with aorto-iliac lesions. Patients with an ankle-brachial index (ABI) below 0.9 in at least one limb, and an absolute claudication distance (ACD) ≤ 500 meters, were included in the study. During the first three months, patient participated to an educational program with educational workshop, and a weekly telephone coaching. In educational session patients were assisted in delimiting walking objectives. Functional parameters were evaluated at 0, 12, and 24 months. Between Feb 2014 and Jan 2019, 112 and 39 PAD patients with IC completed the 12- and 24-month follow-up, respectively. More than a third of the population (42 patients) had significant aorto-iliac artery lesions. In both the overall population and the group of patients with aorto-iliac lesions, the mean initial claudication distance (ICD) increased by 3 times and the mean absolute claudication distance (ACD) by 2, compared to baseline values at 24-month follow-up ( Fig. 1 ). The results of our study indicate that home-based training combined with therapeutic educational programs for patients with PAD who suffer from IC, have a clear long-term beneficial effect in walking performance at 24 months. Patients with aorto-iliac disease can benefit equally from this program than patients with femoral lesions.

A Comparison of Aortoiliac Disease between Eastern and Western Countries.

A variety of diseases are known to develop in the aortoiliac segment; these include abdominal aortic aneurysm (AAA) and aortoiliac occlusive disease. This review summarizes several differences of aortoiliac diseases between eastern and western populations. The prevalence of AAA was higher in western countries (4.57% to 19%) than in eastern countries (0.89% to 4.9%). Greater aortic bifurcation angles were observed in the eastern population, while longer common iliac arteries and aneurysm necks were found in the western population with AAA. However, the angle of the aneurysm was found to be more acute in patients from western countries. Several differences were found between patients from western countries and those from eastern countries regarding the diseases that occur in the aortoiliac segment and their anatomical characteristics. Therefore, different approaches to the treatment of aortoiliac diseases in these two groups should be considered.

In the Current Era of Endovascular Surgery, What is the Role of Axillofemoral Bypass?

Introduction - Nowadays, axillofemoral bypass (AxFB) is viewed as an end-of-line solution for lower limb revascularization, owing to its classically described poor long-term patency and recent advances in endovascular surgery. There is a marked difference in patient profiles in published series of AxFB, reflecting changing procedures indications. The objective of this study is to determine the contemporary profile of patients treated with AxFB and their outcome. Methods - Patients who underwent AxFB surgery in a tertiary hospital from April 2011 to December 2017 were identified. Surgical indication, primary patency, major amputation and death rates were recorded. Patients were grouped in:-Bypass configuration: axillouni vs axillobifemoral;-Previous vascular surgery status: first revascularization procedure vs reintervention;-Primary vascular disease: aortoiliac occlusive disease vs aneurysmal disease,-Emergency character of procedure: urgent (initiated less than 24hours from patient presentation) vs planned (more than 24hours from patient presentation). Groups were compared using Kaplan-Meier survival analysis. Results - 56 patients were included. 44 (78,6%) underwent axillobifemoral bypass; remaining patients underwent axillounifemoral bypass. Median age was 68,18±9,59 years; 94,6% were male. The most prevalent cardiovascular risk factors were HTA (77%) and history of smoking (76%). Primary vascular disease was aneurysmal in 14 patients (25%). The remaining group had aortoiliac occlusive disease. AxFB was an urgent procedure in 11 patients (19,6%). In 30 patients (53,6%), AxFB was the first revascularization performed. Indications for procedure on this group were aorto-iliac occlusive disease (25; 83,3%) and AA thrombosis (5; 16,7%). In patients previously submitted to revascularization (26; 46,4%), the most common previous procedures were aortobifemoral bypass (12; 46,2%), femoro-femoral bypass (12; 46,2%) and EVAR (9; 34,6%). Indications for AxFB on this group were: prosthesis thrombosis (17; 65,4%), secondary aorto-enteric fistulae (7; 26,9%) and prosthesis infection (2; 7,7%). Global primary patency of AxFB was 91,5±4,1% at 1 month, 74,8±7,6% at 1 year, and 56,1±12,8% at 5 years (Fig.1). Group survival analysis showed superior primary patency in aneurysmal disease group (p=0,063), and after urgent procedures (p=0,113). Previous vascular surgery and bypass configuration did not affect long-term primary patency. No patient with aneurysmal disease required major amputation during follow-up. In primary occlusive disease group, 83,4±5,7% patients were free-of-amputation at 1 month, 77,2±6,8% at 1 year and 5 years. Amputation rates were similar regardless previous vascular surgery status, bypass configuration and urgency character of procedure. Median time of survival was 5,1±1,1years. Patients who underwent AxFB had a survival rate of 76,8±5,6% at 1 month, 64,7±6,6% at 1 year, and 50,0±7,8% at 5 years. Survival rates were similar regardless bypass configuration and primary vascular disease. However, patients whose AxFB was a vascular reintervention or an urgent procedure had significant worse long-term survival (p=0,042 and p=0,017, respectively). Conclusion - Axillofemoral bypass, although being an increasingly uncommon procedure, still allows acceptable rates of patency and limb salvage. As patients with aortoiliac disease usually have multiple comorbidities and a short life-expectancy, axillofemoral bypass is attractive owing to its less invasive character.

The Use of Begraft® Balloon-Expandable Covered Stents as Cerab Technique for the Treatment of Aorto-Iliac Aortic Disease

Introduction - Peripheral arterial disease (PAD) affects more than 20% of the population above 70 years old. Nowadays, the treatment of occlusive aorto-iliac disease has moved to an endovascular-first approach in many centers, even for complex TASC C and D lesions. In this situation, balloon-expandable covered stents have demonstrated superior results. However, few options exist when dealing with aortic lesions requiring large diameter covered stents. Methods - To report a case of the use of large diameter BeGraftÒ balloon-expandable covered stents with the CERAB technique in the treatment of aorto-iliac occlusive disease. Results - A 77-year-old man was referred to our Department for pelvis and thigh claudication and impotence worsening over the last 2 years. He underwent an angio-CT scan, which demonstrated a significant tight stenosis of the infra-renal aorta extending to the iliac bifurcation. Flows were monophasic at the femoral level on both sides. The patient was offered percutaneous endovascular treatment using the CERAB technique. Firstly an aortic balloon-expandable covered stent BeGraft (Bentley, Hechingen, Germany) 18x48 mm was placed and dilated to 20mm proximally and then two iliac 10x38mm BeGraft were successfully implanted partially in the first aortic stent. Completion angiography demonstrated a patent aorta, no residual stenosis and a rapid flow down to the limbs. Patient was discharged on the following day. At 1 month follow up, the patient was free from pain during exercise and described normal sexual function. Vascular examination revealed palpable pedal pulses. An angio CT-scan confirmed a patent CERAB, without any complications. Conclusion - To our knowledge, this is the first report of the implantation of a large diameter BeGraft covered stent at the level of the abdominal aorta to treat occlusive disease using the CERAB technique. Aortic lesions are often highly calcified, partially thrombosed and thus difficult to cross. Due to the risk of flow limiting dissection, perforation or embolization, the use of covered stent allows to immediately treat these complications. The CERAB technique has been shown to offer better hemodynamics conditions as compared to kissing stents, reducing the risk of restenosis. BeGraft stent appears to be a safe and valid in the treatment of aorto-iliac stenosis. Further cases and studies are required to confirm this preliminary excellent result.

Outcomes Analysis of 677 Cases from the Multicenter Italian Registry on Primary Endovascular Treatment of Iliac and Aorto-Iliac Arteries Obstructive Disease (Iliacs Registry)

Introduction - Endovascular revascularization has become the first-line strategy for iliac obstructive lesions (IOL), and also used increasingly as an alternative to conventional surgery for complex aorto-iliac obstructive disease (AIOD). Owing to the good results resembling those of open surgery, an endovascular-first strategy have been considered for complex AIOD even in the most recent guidelines if done by an experienced team and if it does not compromise subsequent surgical options. The aim of this study was to analyze the results of the endovascular treatment of IOL and AIOD in a multicenter Italian registry. Methods - Over a 3-year period, ending in December 2017, 677 treatments were performed for IOL and AIOD in eleven Italian hospitals and collected into a dedicated registry database. Intermittent claudication was an indication in 376 (55.5%) patients, whereas critical limb threatening ischemia in 298 (44.0%). Postoperative anti-thrombotic therapy was left at center’s discretion: follow-up evaluation was performed at 1, 6 and 12 months after the intervention. Early (<30 days) major end-points were mortality and major complications; late major end-point was freedom from reintervention. Early results were compared with the Chi-square test and the Wilcoxon’s signed rank test; follow-up results were analyzed with Kaplan-Meier survival estimates andcompared with log-rank test. Univariate and multivariate (forward Cox regression) analysis was used to identify potentially significantpredictors of need for reintervention. Results - We treated 511 (75.4%) males. Overall, mean age was 68 ± 10 (range, 22-96; IQR, 62-76). Accordingly to the TASC II classification we treated 98 (14.5%) type A, 163 (24.1%) type B, 164 (24.2%) type C, and 248 (36.6%) type D lesions: stenoses were 370 (56.2%) and occlusions were 288 (43.8%). We used a totally percutaneous approach in 473 (69.9%): hybrid intervention was carried out in 204 (30.1%) patients, mostly with femoral endarterectomy plus patch plasty. A covered stent was implanted in 207 (30.6%) cases. Overall, a kissing-stent configuration was performed in 243 (36.1%) lesions. Primary technical success was obtained in 671 (99.3%) cases: earl mortality occurred in 3 (0.4%) cases, and postoperative complication was observed in 51 (7.5%) patients. Mean ankle-brachial index improved significantly from preoperative to postoperative period (0.5 ± 0.2 vs. 0.9 ± 0.1, P < 0.001). Median hospitalization was 5 days (IQR, 2-7). Early thrombosis, major amputation, and mortality was observed in 10 (1.5%), 3 (0.5%), and 4 (0.6%) cases, respectively. During the follow-up 21 (3.1%) died: the estimated survival was 96.3% at 12 months (95%CI: 93.8-97.8) and 90.2% at 36 months (95%CI: 82.7-94.7). Follow-up thrombosis occurred in 17 (2.5%) cases. Estimated primary patency and freedom from reintervention was 96% (IC95%: 93.3-97.7) and 97.2% (95%CI: 94.5-98.6) at 12 months, and 95% (95%CI: 89.0-97.6) for both outcomes at 36 months. At Cox regression analysis, no pre/intra/or-postoperative parameters independently predicted loss of primary patency and need for reintervention. Conclusion - In this “real world” registry experience, endovascular revascularization showed to be safe and effective. No independent predictors were found to be associated with the need of reintervention thus indicating that endovascular revascularization for IOL and AOID can be an effective and durable first-line alternative even for the treatment of complex AOID.

The Role of Female Gender on Outcomes After Stenting for Aorto-Iliac Arterial Obstructive Disease

The Role of Female Gender on Outcomes After Stenting for Aorto-Iliac Arterial Obstructive Disease

Cost-Effectiveness of Revascularisation in Patients with Intermittent Claudication on Best Medical Treatment and Unsupervised Training in a Randomised Controlled Trial

Introduction - Invasive vascular procedures are an integral part of intermittent claudication (IC) treatment, despite the relative lack of evidence to support its long-term benefits and cost-effectiveness. We wanted to compare the cost-effectiveness of revascularisation together with best medical therapy (BMT) with that of BMT alone in patients with IC. Methods - In this prospective, randomised controlled trial, consecutive patients with mild-to-severe IC due to aortoiliac or femoropoliteal disease were allocated either to BMT alone (including a structured, non-supervised exercise programme) or to revascularisation together with BMT. In-patient and out-patient costs were obtained prospectively over 24 months of follow-up. Mean improvement in quality-adjusted life years (QALYs) was calculated using the EuroQol 5D-3L questionnaire, and the cost-effectiveness was assessed as the cost per QALY gained. Results - The mean cost per patient in the BMT group was €1 901 whereas it was €8 280 in the group treated with revascularisation in addition to BMT (difference in cost: p < 0.01). Revascularisation in addition to BMT resulted in a mean gain in QALYs of 0.16 per patient (p < 0.01), giving an incremental cost-effectiveness ratio of €42 881 per QALY. Conclusion - The costs associated with revascularisation together with BMT in patients with IC were about four times higher than for BMT alone. However, since health-related quality of life also improved, the incremental cost-effectiveness ratio of revascularisation was within the accepted threshold for public willingness to pay according to the Swedish national guidelines, but exceeded that in the British National Institute for Health and Care Excellence guidelines.

Preprocedural Cross-Sectional Imaging Prior to Percutaneous Peripheral Arterial Disease Interventions.

Preprocedural cross-sectional imaging (PCSI) for peripheral artery disease (PAD) may vary due to patient complexity, anatomical disease burden, and physician preference. The objective of this study was to determine the utility of PCSI prior to percutaneous vascular interventions (PVIs) for PAD. Patients receiving first time lower extremity angiograms from 2013 to 2015 at a single institution were evaluated for PCSI performed within 180 days, defined as computed tomography angiography (CTA) or magnetic resonance angiography (MRA) evaluating abdominal to pedal vasculature. The primary outcome was technical success defined as improving the target outflow vessels to <30% stenosis. Of the 346 patients who underwent lower extremity angiograms, 158 (45.7%) patients had PCSI, including 150 patients had CTA and 8 patients had MRA. Of these, 48% were ordered by the referring provider (84% at an outside institution). Preprocedural cross-sectional imaging was performed at a median of 26 days (interquartile range: 9-53) prior to the procedure. The analysis of the institution's 5 vascular surgeons identified PCSI rates ranging from 31% to 70%. On multivariate analysis, chronic kidney disease (odds ratio [OR] = 0.35; 95% confidence interval [CI]: 0.17-0.73) was associated with less PSCI usage, and inpatient/emergency department evaluation (OR = 3.20; 95% CI: 1.58-6.50) and aortoiliac disease (OR = 2.78; 95% CI: 1.46-5.29) were associated with higher usage. After excluding 31 diagnostic procedures, technical success was not statistically significant with PSCI (91.3%) compared to without PCSI (85.6%), P = .11. When analyzing 89 femoral-popliteal occlusions, technical success was higher with PCSI (88%) compared to procedures without (69%) P = .026. Our analysis demonstrates that routine ordering of PCSI may not be warranted when considering technical success of PVI; however, PCSI may be helpful in treatment planning. Further studies are needed to confirm these findings in another practice setting, with more prescriptive use of PCSI to improve procedural success, and thereby improve the value of PCSI.

AAA 12. Juxtarenal Aortoiliac Occlusive Disease—Contemporary Results of Surgical Management and Outcome in a Tertiary Care Center in North India

Peripheral artery disease involving the abdominal aorta and iliac arteries due to atherosclerosis is one of the most common therapeutic challenges faced by vascular surgeons. Although there is a paradigm shift in the management of aortoiliac occlusive disease, most patients with extensive aortoiliac disease with juxtarenal aortic occlusion are being referred to vascular surgeons for aortobifemoral bypass as endovascular treatment is complex and long-term data are not available about its durability. During the last 3 years, 15 patients have been managed surgically at our institute with promising results. All patients were planned for conventional aortobifemoral bypass surgery. The surgical technique included control of bilateral renal arteries and suprarenal aortic clamp placement, infrarenal aortotomy and thrombectomy, thorough aortic flushing, and shifting of the clamp to the infrarenal aorta, followed by standard bypass grafting. Aortic clamp time and renal ischemia time were recorded. Fifteen patients (mean age, 54 years) had tissue loss (minor, eight; major, four); claudication pain was the most common symptom. Smoking (86%), diabetes (36%), hypertension (18%), and coronary artery disease (8%) were the most important risk factors. There were no patients with postoperative renal dysfunction or any need for renal replacement therapy. At mean follow-up of 14 months, all the patients were doing fine with good distal blood flow in limbs, confirming graft patency (Figs 1 and 2). Aortobifemoral bypass remains the “gold standard” in management of juxtarenal aortoiliac occlusive disease because of durable bypass with good long-term results. Risk of renal ischemia is low if the procedure is planned well. We used coated polyester graft in all patients, which has shown good midterm graft patency. This study helps in identifying such complex diseased patients and how they can be managed surgically to improve their long-term survival.Fig 2Postoperative computed tomography angiogram scans showing patent grafts with good distal outflow (anteroposterior and lateral views).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Midterm Results of Endovascular Treatment for Complete Iliac Axis Occlusions Using Covered Stents

Endovascular treatment of complex aortoiliac disease is seeing a growing popularity despite the Trans-Atlantic Inter-Society Consensus (TASC) II recommendations for open surgery in this cases. However, the available evidence does not focus particularly on patients with complete unilateral iliac axis obstruction (CIAO) (TASC II D4 group). This study reports mid-term results of endovascular therapy with covered stents for CIAO. This is single-center retrospective review of patients with CIAO endovascular treatment from January 2015 to December 2017 (3years). Two types of covered stents were used, alone or combined: the Viabahn self-expandable stent (W. L. Gore, Flagstaff, AZ) and the Advanta V12 balloon-expandable stent (Atrium-Maquet, Hudson, NH). Thirty-day outcomes, long-term patency (assessed with Kaplan-Meier estimates), in-hospital stay, and limb salvage were analyzed. Thirty-nine patients with CIAO were treated in the period (87.2% male, mean age 64.3±9years). A majority presented with critical limb ischemia (56.4%, n=22). Recanalization could be accomplished from an ipsilateral or contralateral femoral access in 82.1% of patients (1 case needed the use of a re-entry device), and from a left brachial access in 17.9%. Technical success was 100%. About 66.7% of cases received an aortic kissing stent technique. Common femoral artery/profundoplasty with prosthetic or bovine patch was associated with 74.3% of cases. Thirty-day mortality was 2.6% (1/39). Primary, assisted, and secondary patency rates at 24months were all 96.8%. Mean in-hospital stay was 5days; no limb loss was registered during follow-up. Endovascular treatment of complete iliac axis occlusions can offer comparable midterm patency rates to open surgery aortoiliac femoral bypass, when an adequate combination of balloon and self-expandable covered stents is used and an appropriate outflow through the common femoral artery is warranted.