Complex Aortoiliac Occlusive Disease Research Articles

Endovascular and Hybrid Interventions for Aortoiliac Occlusive Disease in Patients with Intermittent Claudication

IntroductionSignificant practice variability exists regarding the management of intermittent claudication (IC) across anatomic segments. We sought to answer the question of whether the safety, efficacy, and durability outcomes of an endovascular approach with or without common femoral endarterectomy for complex aortoiliac occlusive disease (AIOD) justify a surgical approach in patients presenting with IC. MethodsA retrospective single-center review of all patients who were treated using an endovascular approach for AIOD with or without CFE from 2010 to 2020 was conducted. The review was limited to those with symptoms of IC. Patient- and limb-level preoperative presentations were reviewed. The outcomes were postoperative complications and patency rates in addition to freedom from re-intervention. Subgroup analyses were conducted to compare patients who underwent endovascular and hybrid procedures. ResultsA total of 245 limbs in 180 consecutive patients were analyzed. The mean age was 65 years and 61% were males. Of 176 patients, 101 (57%) had TASC class D and 18 (10%) had Class C. Eleven limbs (7.4%) had access site complications, 12 (7.9%) had surgical wound complications, and below-the-knee amputation was observed in 2 limbs (0.82%) (2 patients). Two (1.0%) patients had perioperative MI, 1(0.5%) stroke, 1(0.5%) AKI that progressed to dialysis, and no 30-day mortality. Rutherford’s classification was improved during the follow-up period. The 1-, 2- and 5-year primary patency rates were 94%, 77%, and 58%; primary-assisted patency rates were 98%,91%, and 79%, respectively; and secondary patency rates were 100% for all follow-up periods. Patients who had concurrent CFE were likely to have hypertension, hyperlipidemia, and anatomically more diffuse disease. No significant differences in patency or reintervention-free survival were observed, though event rates were low in both outcomes and trended toward a protective effect with CFE. ConclusionEndovascular management for complex AIOD with or without CFE for IC patients is safe, effective, and durable. These results justify an active, patient-centered approach for this advanced anatomic disease pattern. The morbidity of a hybrid approach in the CFE subset is low and treatment vessel patency is excellent. The presence of anatomically advanced AIOD is not prohibitive for the treatment of patients with IC, however careful patient selection is essential.

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.

Comparative outcomes of aortobifemoral bypass with or without previous endovascular kissing stenting of the aortoiliac bifurcation

ObjectiveThe aim of this multicenter national study was to compare the outcomes of primary open surgery by aorto-bifemoral bypass (ABFB) with those performed after a failed endovascular treatment (EVT) by kissing stent technique for complex aortoiliac occlusive disease (AIOD) lesions (TransAtlantic Inter-Society Consensus [TASC] II C and D). MethodsAll consecutive ABFB cases carried out at 12 vascular surgery centers between 2016 and 2021 were retrospectively collected and analyzed. Data included patients’ baseline demographics and clinical characteristics, procedural details, perioperative outcomes, and follow-up results (survival, patency, amputation). The study cohort was divided into two groups based on indications for ABFB: primary treatment vs secondary treatment after EVT failure. ResultsOverall, 329 patients underwent ABFB during the study period (71% males; mean age, 64 years), of which 285 were primary treatment and 44 were after prior EVT. At baseline, no significant differences were found between study groups in demographics and clinical characteristics. TASC C and D lesions were similarly represented in the study groups (TASC C: 22% vs 78%; TASC D: 16% vs 84%). No major differences were found between study groups in terms of procedural details, early mortality, and perioperative complications. At 5 years, primary patency rates were significantly higher for primary ABFB (88%; 95% confidence interval [CI], 93.2%-84%) as compared with ABFB after prior EVT (69%; 95% CI 84.9%-55%; log rank P value < .001); however, the 5-year rates of secondary patency (100% vs 95%; 95% CI, 100%-86%) and limb salvage (97%; 95% CI, 99%-96 vs 97%; 95% CI, 100%-94%) were similar between study groups. ConclusionsSurgical treatment of TASC C/D AIOD with ABFB seems to be equally safe and effective when performed after prior EVT, although primary ABFB seemed to have higher primary patency rates. Despite the need for more frequent reinterventions, secondary patency and limb salvage rates were similar. However, future large prospective trials are required to confirm these findings.

AFX unibody stent graft: Effective and safe for the treatment of severe aorto-iliac occlusive disease.

The primary objective of this study was to determine the primary, assisted primary and secondary patency rates of the Endologix AFX stent-graft in patients considered high risk for open surgery with complex aorto-iliac occlusive disease. The secondary objective was to determine 30-day major adverse cardiovascular and cerebrovascular events. A retrospective review was undertaken of clinical records of 38 patients who underwent AFX stent-graft placement for aorto-iliac occlusive disease from 2016 to 2019. Patient data was de-identified and entered into a REDcap secure database. Descriptive statistical analysis (means and standard deviations) and Kaplan-Meier survival curves were created to determine the duration of patency of the AFX stent-graft system. Primary patency rates at 6, 12 and 24months were 92%, 92% and 84%, respectively. Assisted primary patency rates at these times were 100%, 100% and 93% with secondary patency of 100% maintained throughout. The incidence of 30-day major adverse cardiovascular and cerebrovascular events was 8% and major adverse limb events was 3%. One death unrelated to the AFX device occurred during the study period though outside of the 30-day peri-operative period. Primary, assisted primary and secondary patency rates of AFX stent-grafts, when used to treat aorto-iliac occlusive disease, are high. This study supports the use of the AFX stent-graft for the endovascular treatment of complex aorto-iliac occlusive disease as an alternative to other endovascular options as well as a safe alternative to open aorto-iliac or aorto-femoral bypass in patients who are at high risk for open procedures.

Open Versus Endovascular Repair With Covered Stents for Complex Aortoiliac Occlusive Disease: Cost Analysis Results

The aim of this work is to value cost-effectiveness of complex aortoiliac occlusive disease (AIOD) revascularization, by comparing in-hospital clinical outcomes and detailed costs of hospitalization of open and endovascular techniques. This observational single-center retrospective cohort study included all patients who underwent AIOD revascularization from May 2008 to February 2018 and met inclusion and exclusion criteria. Patients were divided into 2 groups: open surgical repair and endovascular repair. Inclusion criteria were type C and D AIOD, and type of intervention: aorto-bifemoral bypass and covered kissing stenting. Costs were directly compared between the 2 groups, and subsequently a multivariate logistic regression model was performed to define which group most influenced major in-hospital costs. Cox proportional hazard models were used to identify predictors of long-term mortality and primary patency (PP). The 2 groups included 50 patients each, and all patients had a bilateral iliac axis revascularization. Mean age was 67±9years and 71% of patients were males. The open surgical repair group had a significantly longer length of hospitalization (P<0.001) and in-hospital medical complications rate (22%, P=0.003). No differences were found in the total cumulative cost of hospitalization, including ward, intensive care unit, and operating room. In a multivariate logistic model, higher total hospitalization costs were not significantly associated with either one or the other type of treatment. We did not find any statistically significant differences in overall medium-term survival (P=0.298) and PP (P=0.188), which were not influenced by the type of revascularization on Cox proportional hazard models (overall survival: hazard ratio 2.09 confidence interval 95% [0.90-4.84] P=0.082; PP: hazard ratio 1.82 confidence interval 95% [0.56-6.16] P=0.302). Total in-hospital stay cost analysis did not reveal significant differences between aorto-bifemoral bypasses and covered kissing stentings for AIOD revascularization.

Open management of complex infrarenal aortic occlusive disease.

Open aortic reconstruction for complex aortoiliac occlusive disease is a time-honored and durable solution. Symptoms manifest as disabling claudication or chronic limb threatening ischemia in patients with multilevel disease. Advanced endovascular techniques have supplanted a large volume of aortic surgery. Nonetheless, it is essential for surgeons-in-training to learn and hone their skills in open aortic surgery. Comprehensive literature review over the past 50 years was conducted on the topics of "aortic occlusive disease," "aortic bypass," and "iliofemoral bypass." Pertinent articles were selected for inclusion as references. The technical aspects of the various aortoiliac exposures are described and selected case images were chosen from the senior author's experience. This review paper details the various operative approaches to open aortoiliac revascularization with emphasis on "tips and tricks" for the learner.

Midterm Outcomes of Kissing Covered Self-Expanding Stents for Reconstruction of Complex Aortoiliac Occlusive Disease

We sought to investigate the midterm results of kissing self-expanding covered stents (SECSs) for the reconstruction of aortic bifurcation in complex aortoiliac occlusive disease. Data of consecutive patients who had undergone endovascular treatment for aortoiliac occlusive disease were screened. Only patients with TransAtlantic Inter-Society Consensus (TASC) class C and D lesions treated by bilateral iliac kissing stents (KSs) were included. Midterm primary patency, risk factors, and limb salvage rates were analyzed. Follow-up results were analyzed using the Kaplan-Meier curves. Cox proportional hazards models were used to identify the predictors of primary patency. A total of 48 patients (95.8% men; mean age, 65.3±10.2years) were treated with kissing SECSs. Of them, 17 patients had TASC-II class C lesions and 31 had class D lesions. There were 38 total occlusive lesions, with a mean occlusive lesion length of 108.2±57.3mm. The overall mean lesion length was 140.3±60.5mm, and the mean length of implanted stents in the aortoiliac arteries was 141.9±59.9mm. The mean diameter of the deployed SECSs was 7.8±0.5mm. The mean follow-up time was 36.5±15.8months, and the follow-up rate was 95.8%. At 36months, the overall primary patency, assisted primary patency, secondary patency, and limb salvage rates were 92.2%, 95.7%, 97.8%, and 100%, respectively. Univariate Cox regression analysis revealed that stent diameter ≤7mm (hazard ratio [HR]: 9.53; 95% confidence interval [CI] 1.56-57.94, P=0.014) and severe calcification (HR: 12.66; 95% CI 2.04-78.45, P=0.006) were significantly associated with restenosis. Multivariate analysis showed severe calcification to be the only significant determinant of restenosis (HR: 12.66; 95% CI 2.04-78.45, P=0.006). Kissing SECSs provide good midterm results for the treatment of aortoiliac occlusive disease. A stent diameter >7mm is a potent protective factor against restenosis. Because severe calcification appears to be the only significant determinant of restenosis, patients with severe calcification require close follow-up.

Editorial on current management of complex aorto-iliac occlusive disease.

Editorial on current management of complex aorto-iliac occlusive disease.

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

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.

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

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

Outcome Comparison between Open and Endovascular Management of TASC II D Aortoiliac Occlusive Disease

Endovascular management of complex aortoiliac occlusive disease (AIOD) has been described as a viable alternative to open surgical reconstruction. To date, few studies have directly compared the 2 techniques. We therefore, evaluated short and mid- term outcomes of open and endovascular therapy in TASC II D AIOD patients. TASC II D patients undergoing treatment between January 2009 and December 2016 were retrospectively reviewed. Patient demographics, clinical data, and outcomes (complications [technical and systemic] and graft patency) were collected. The primary outcome of this study was primary graft patency. Patients were compared according to treatment group (open versus endovascular). Kaplan-Meier curves were used to analyze follow up results. A total of 75 consecutive patients (open: 30; endovascular: 45) were included in this analysis. In the endovascular group, 25 (55.6%) patients were managed using a hybrid approach with 100% technical success. Critical limb ischemia was the indication for intervention in 16.0% of this cohort (open, 13.3% vs. endovascular, 17.8%, P=0.397). Overall, there were no significant differences in gender (male: open, 50.0% vs. endovascular, 55.6%, P=0.637) or age (54.5±5.9years vs. 57.0±8.7years, P=0.171). No in hospital deaths occurred in this cohort. The overall complication rate was significantly higher in the open group (43.3% vs. 17.8%, OR 3.5, 95% CI [1.2-10.1], P=0.016) with peri-operative systemic complications being more likely in the open cohort (40.0% vs. 6.7%, OR 9.3, 95% CI [2.3-37.3], P<0.001) while technical complications did not differ between the 2 groups (6.7% vs. 11.1%, OR 0.6, 95% CI [0.1-3.1], P=0.517). Follow up data was available for 68 patients (90.7%), for a mean of 21.3±17.1months (range: 1-72months). Re-intervention rates were significantly higher in the endovascular group (3.3% vs. 20.0%, OR 7.2, 95% CI [1.1-14.3], P=0.038). The overall primary patency at 2 years was significantly higher in the open group (96.7% vs. 80.0%, OR 7.2, 95% CI [1.2-60.5], P=0.038). Cox regression analysis revealed separation of the primary outcome for open therapy relative to endovascular repair (log rank, P=0.320). In this comparison of open and endovascular therapy for complex AIOD, endovascular therapy was associated with high initial technical success and fewer in-hospital systemic complications but also high re-intervention rates when compared to open repair. Further prospective studies aimed at reduction of complications, optimization of patency, and patient selection for such procedures is warranted.

Outcomes From the Multicenter Italian Registry on Primary Endovascular Treatment of Aortoiliac Occlusive Disease

Purpose: To report the results of endovascular treatment of iliac and complex aortoiliac occlusive disease (AIOD) in a multicenter Italian registry. Materials and Methods: A retrospective, multicenter, observational cohort study analyzed 713 patients (mean age 68±10 years; 539 men) with isolated iliac and complex aortoiliac lesions treated with primary stenting between January 2015 and December 2017. Indications for treatment were claudication in 406 (57%) patients and critical limb ischemia in 307 (43%). According to the TransAtlantic Inter-Society Consensus II (TASC) classification, the lesions were categorized as type A (104, 15%), type B (171, 24%), type C (170, 24%), and type D (268, 37%). Early (<30 days) endpoints included mortality, thrombosis, and major complications. Late major outcomes were primary and secondary patency and freedom from reintervention as estimated by Kaplan-Meier analysis; estimates are given with the 95% confidence intervals (CIs). Associations between baseline variables and primary patency were sought with multivariate analysis; the results are presented as the hazard ratio (HR) and 95% CI. Results: Technical success was achieved in 708 (99%) lesions; in-hospital mortality was 0.6% (n=4). The median follow-up was 11 months (range 0–42). The estimated primary patency rate was 96% (95% CI 94% to 97%) at 1 year and 94% (95% CI 91% to 96%) at 2 years. The estimated secondary patency was 99% (95% CI 97% to 99%) at 1 year and 98% (95% CI 95% to 99%) at 2 years. The estimated freedom from reintervention was 98% (95% CI 96% to 99%) at 1 year and 97% (95% CI 94% to 98.5%) at 2 years. Cox regression analysis demonstrated that the application of a covered stent was associated with an increased need for reintervention (HR 1.4, 95% CI 1.10 to 1.74, p=0.005). Chronic obstructive pulmonary disease was associated with decreased primary patency (HR 3.7, 95% CI 1.25 to 10.8, p=0.018). Conclusion: Endovascular intervention with primary stent placement for aortoiliac occlusive disease achieved satisfactory 2-year patency regardless of the complexity of the lesion. Almost all TASC lesions should be considered for primary endovascular intervention if suitable.

Long-term Results of Endovascular Treatment of TASC C and D Aortoiliac Occlusive Disease with Expanded Polytetrafluoroethylene Stent Graft

The aim of this study is to retrospectively analyze the early and long-term outcomes of endovascular treatment of Trans-Atlantic Inter-Society Consensus II class C and D (TASC II) aortoiliac occlusive disease with an expanded polytetrafluoroethylene-covered stent graft. Between January 2006 and November 2017, 61 patients (53 males, 8 females), with symptomatic aortoiliac stenotic and/or occlusive disease, were treated with VIABAHN (W.L. Gore and Associates, Flagstaff, Ariz) at 2 University medical centers. The morphology of the lesions was evaluated and classified by contrast-enhanced computed tomography angiography. Demographic data, operation details, and postoperative outcomes were collected. Follow-up data were analyzed by a life-table analysis (Kaplan-Meier test). Mean age of the patients was 64.89±10.77years (range 44-89). Thirty-seven patients (60.7%) presented with severe claudication (Rutherford 3), whereas 21 (34.4%) were in Rutherford class 4 and the remaining 3 patients (4.9%) suffered from necrotic lesions (Rutherford 5/6). Fifty-six patients were smokers (91.8%), 38 (62.3%) had hypertension, 23 (37.7%) had coronary artery disease, 30 (40.2%) had dyslipidemia, 18 (29.5%) had chronic obstructive pulmonary disease, 6 (9.5%) had renal insufficiency (serum creatinine>2.0mg/dL) and 24 (39.3%) had diabetes. Technical success was achieved in 59/61 patients (96.7%) with 16 patients (26.2%) requiring combined percutaneous brachial access to obtain iliac recanalization. Perioperative mortality was 1.6%, whereas postoperative major complications occurred in 2 patients (3.6%). The mean number of VIABAHN placed was 1.77/patient. Mean follow-up was 31.5months (range 1-108) and primary patency at 36 months was 94.9%. Two major amputations of the lower limbs occurred during the follow-up. Open surgery with the aortobifemoral bypass has been the gold standard treatment for complex aortoiliac occlusive disease although complications and mortality still remain significant issues. Our results suggest that endovascular therapy of TASC C and D iliac lesions using the VIABAHN stent graft is feasible, effective, and has good, long-term patency.

IP079. Outcome Comparison Between Open and Endovascular Management of TASC II D Aortoiliac Occlusive Disease

Endovascular management of complex aortoiliac occlusive disease (AIOD) has been described as a viable alternative to open surgical reconstruction. To date, few studies have directly compared the two techniques. We therefore, evaluated short- and midterm outcomes of open and endovascular therapy in TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) D AIOD patients. TASC II D patients undergoing treatment between January 2009 and Dec 2016 were retrospectively reviewed. Patient demographics, clinical data, and outcomes (technical and systemic complications and graft patency) were collected. The primary outcome of this study was primary graft patency. Patients were compared according to treatment group (open vs endo). Kaplan-Meier curves were used to analyze follow-up results. The analysis included 75 patients (open: 30; endo: 45). In the endovascular group, 27 patients (60.0% of endo) were managed using a hybrid approach with 100% technical success. Critical limb ischemia was the indication for intervention in 37.3% of this cohort (open, 40.0% vs endo, 35.6%; P = .397). Overall, there were no significant differences in gender (male: open, 50.0% vs endo, 55.6%; P = .646) or age (open, 54.5 ± 6.0 years vs endo, 56.9 ± 8.7 years; P = .280). No in-hospital deaths occurred in this cohort. The overall complication rate was significantly higher in the open group (open, 43.3% vs endo, 17.8%; odds ratio [OR], 3.5; 95% confidence interval [CI], 1.2-10.1; P = .016) with perioperative systemic complications being more likely in the open cohort (open, 40.0% vs endo, 6.7%; OR, 9.4; 95% CI, 2.3-37.1; P < .001), while technical complications did not differ between the two groups (open, 6.7% vs endo, 11.1%; OR, 0.6; 95% CI, 0.1-3.1; P = .695). Follow-up data were available for 68 patients (90.7%), for a mean of 21.3 ± 17.1 months. Reintervention rates were significantly higher in the endo group (open, 3.3% vs endo, 20.0%; OR, 7.2; 95% CI, 1.1-14.3; P = .038). The overall primary patency was significantly higher in the open group (open, 96.7% vs endo, 80.0%; OR, 7.3; 95% CI, 1.1-60.5; P = .038). Kaplan-Meier curves revealed separation of the primary outcome for open therapy relative to endovascular repair (log-rank, P = .320; Fig). In this head-to-head comparison of open and endovascular therapy for complex AIOD, endovascular therapy was associated with high initial technical success and fewer in-hospital systemic complications but also high reintervention rates when compared to open repair. Further prospective studies aimed at reduction of complications, optimization of patency, and patient selection for such procedures is warranted.

Endovascular management of Trans-Atlantic Inter-Society Consensus C and D aortoiliac occlusive disease as a feasible, effective, and durable intervention

Context The progress and innovations in endovascular tools have replaced standard surgical intervention with endovascular intervention, including long, complex lesions. Aim The aim of the study was to evaluate the results of endovascular management as the first-approach intervention for symptomatic extensive Trans-Atlantic Inter-Society Consensus (TASC) C and D aortoiliac disease. Patients and methods This was a prospective study. Fifty patients with long, complex TASC C and D aortoiliac lesions underwent revascularization by endovascular-first approach. Technical success and follow-up results after 6, 12, and 24 months were documented. SPSS software version 18 was used for statistical analyses. Results Of the 50 patients, 84% were male. All the patients had TASC C and D lesions and 66% of them had critical limb ischemia. All the patients were treated by endovascular-first approach. A total of 92 stents were used, of which 66.3% were balloon mounted, and they were located in the common iliac artery. The technical success rate was 90%, and the ankle–brachial (A/B) index improved significantly (P=0.0001). The primary patency rates were 100, 81.8, and 80% at 6, 12, and 24 months, respectively. A total of 6.6% of patients developed major complications, which were successfully managed. Mortality rate was 2.2%, which was not procedure related. Conclusion The endovascular-first approach could be a good alternative and replace the standard surgical management for long, complex aortoiliac occlusive disease.

Initial Experience With Covered Endovascular Reconstruction of the Aortic Bifurcation in Conjunction With Chimney Grafts

Purpose: To show feasibility of the covered endovascular repair of the aortic bifurcation (CERAB) technique in conjunction with chimney grafts in aortic side branches for complex aortoiliac occlusive disease. Methods: Two European centers and one facility located in New Zealand participated in a retrospective observational study that enrolled 14 consecutive patients (mean age 61.2±8.9 years; 11 men) treated with CERAB in conjunction with chimney graft(s) between December 2012 and May 2015. Indications for treatment included disabling claudication in 9 and critical limb ischemia in 5. Lesions were classified as TransAtlantic Inter-Society Consensus II B (n=1), C (n=1), or D (n=12). Results: A total of 15 chimney grafts were used to perfuse the inferior mesenteric artery (n=8), the right renal artery (n=4), and the left renal artery (n=3). Technical success was achieved in all cases. Procedural complications included 5 unintended dissections and 1 vessel thrombosis, all of which were successfully treated intraoperatively. Five patients developed access-site hematoma/ecchymosis (3 at the brachial access). Mean follow-up was 12 months (range 6–24) without death or loss to follow-up. One patient suffered occlusion of a CERAB limb and an IMA chimney graft; the former was recanalized, but the IMA graft was not; there were no signs of bowel ischemia. Ankle-brachial indices significantly increased from 0.54 (range 0.47–0.60) preoperatively to 0.97 (range 0.90–1.00) in 11 patients examined at 12 months, and all patients had an improvement in the Rutherford category. All CERAB limbs, including the one recanalized, were patent at the most recent follow-up, as were 14 of 15 chimney grafts. Conclusion: Chimney-CERAB is technically feasible and may offer an alternative to open surgery for complex aortoiliac occlusive disease. Further prospective studies are needed to confirm these findings.

Outcomes of covered expandable stents for the treatment of TASC D aorto-iliac occlusive lesions.

Aortoiliac arterial occlusive disease is frequently encountered in the management of lower limb vascular insufficiency. We report our experience with covered balloon-expandable stents for treatment of TASC D lesions of the abdominal aorta and common iliac arteries. A retrospective study of 30 patients who underwent aortoiliac stenting with the Atrium Advanta V12 from March 2010 to September 2012 was conducted. Patient demographic data, clinical signs and symptoms and procedural details were recorded. Outcomes assessed were primary patency, secondary patency, technical success, complications, limb salvage and survival. Median age was 67 years (range 48-84) and 40% of patients underwent treatment for critical limb ischaemia. Median follow-up was 13 months (range 3-38 months). Stent configuration comprised of long iliac stents in 20 patients, a large diameter aortic stent with iliac stenting in six patients, and aortic stent alone in four patients. Radiological success was achieved in 100% and the complication rate was 6%. Primary patency at 6, 12 and 24 months was 97%, 90% and 79%, respectively. Four cases of in-stent stenosis were reported, with three of these undergoing re-interventions resulting in a secondary patency rate of 97% at the end of follow-up. One patient death occurred within the follow-up period. This case series demonstrates that treatment of complex aortoiliac occlusive disease with covered balloon-expandable stents can have acceptable results with good patency and good clinical outcome. Secondary patency rates are comparable to open surgical revascularisation, with lower morbidity.

Abstract 18309: Outcomes of Single Versus Kissing Stenting Technique in Lateralized Complex Aortoiliac Bifurcation Lesion

Backgrounds: Kissing stenting technique has been frequently performed even in the cases of unilateral aortoiliac diseases in order to protect contralateral common iliac artery (CIA) with intermediate plaque burden. However, kissing stenting is associated with loss of access from contralateral side for future revascularization. We compared the outcomes of single versus kissing stenting technique in lateralized complex aortoiliac occlusive disease. Methods: From Jan. 2006 to Dec. 2012, we retrospectively enrolled 86 consecutive patients (73 males, 67±9 years) treated with a single stenting technique and 33 patients (29 males, 68±8 years) treated with a kissing stenting technique for lateralized complex aortoiliac bifurcation lesions. A lateralized complex aortoiliac bifurcation lesion was defined as a significant unilateral CIA ostial stenosis (&gt;70%) combined with an intermediate (30~50%) stenosis of contralateral CIA. Results: Single stenting and kissing stenting was successfully performed in all patients without procedure-related major complications. However, in the single stenting group, bailout stenting in contralateral CIA was required in two (2.3%) cases due to unfavorable plaque shift. Median follow up duration of the single and the kissing stenting group was 24 (3~88) and 14 (3~82) months, respectively. The primary patency of the ipsilateral CIA in the single stenting group was 93.9% comparable with 94.9% in the kissing stent group (OR 0.823, 95% CI 0.157-4.298). Target lesion revascularization occurred in 5 (6%) cases of the single stenting group and in 2 (6.1%) cases of the kissing stenting group. Progression of the contralateral un-stented CIA requiring additional revascularization was observed in only 2 (2.4%) cases of the single stenting group during follow up. Conclusions: Single stenting technique in lateralized complex aortoiliac bifurcation lesion was relatively safe and showed comparable outcomes as the kissing stenting technique.

Reconstructive surgery for complex aortoiliac occlusive disease in young adults

Although aortoiliofemoral bypass grafting is the optimal revascularization method for patients with severe aortoiliac occlusive disease (AIOD), previous studies have documented poor patency rates in young adults. This study investigated whether young patients with AIOD have worse outcomes in patency, limb salvage, and long-term survival rates after reconstructive surgery than their older counterparts. Patients aged≤50 years undergoing reconstructive surgery at our institution for AIOD between 1995 and 2010 were compared with a cohort of randomly selected patients aged≥60 years (two for each of the young patients, matched for year of operation), analyzing demographics, risk factors, indications for surgery, operative details, and outcomes. Among 927 consecutive patients undergoing primary surgery for AIOD, 78 (8.4%) aged≤50 years (mean age, 48.4 years) and 156 older control patients (mean age, 71.2 years) were identified. The younger patients were mainly men (81%) and 59% had surgery for limb salvage and 41% for disabling claudication (P=.02). Compared with older patients, they were significantly more likely to be smokers (90% vs 72%; P=.002) and had previously needed significantly more inflow procedures (28% vs 16%; P=.03). Only one death occurred perioperatively (30-day) among the control patients, and no major amputations or graft infections occurred in either group. The need for subsequent infrainguinal reconstructions was greater in the younger patients (18% vs 7%; P=.01). The primary patency rates were inferior in the younger patients at 5 years (82% and 75%) and 10 years (95% and 90%; P=.01), whereas assisted secondary patency (89% and 82% vs 96% and 91%; P=.08), secondary patency (93% and 86% vs 98% and 92%; P=.19), limb salvage (88% and 83% vs 95% and 91%; P=.13), and survival rates (87% and 76% vs 91% and 84%; P=.32) were comparable in the two groups. This study shows that despite a higher primary graft failure rate than that in older patients, aortoiliofemoral revascularization for complex AIOD is a safe procedure for younger patients with disabling claudication or limb-threatening ischemia, providing they are willing to follow a regular protocol to complete their postoperative surveillance and to undergo graft revision as necessary.

Combined Direct Repair and Inline Inflow Stenting in the Management of Aortoiliac Disease Extending Into the Common Femoral Artery

Describe a hybrid approach to simplify management of complex aortoiliac occlusive disease (AIOD) extending into the common femoral artery (CFA). Retrospective review of 56 patients who underwent hybrid management of AIOD extending into CFA between January 2003 and February 2007. Two distinct hybrid approaches were compared: Inline (iliac stenting continuous with an open CFA reconstruction, 38 limbs in 37 patients) and tandem (noncontiguous stenting of an upstream iliac segment, 20 limbs in 19 patients). The median follow-up duration was 15 ± 12 months in the inline group and 24 ± 12 months in the tandem group. Technical success was achieved in all but 1 procedure. Clinical and hemodynamic responses to the interventions and limb loss rates were comparable in both groups. Survival table analysis showed no significant difference between inline and tandem reconstructions. Inline stenting represents a lesser invasive revascularization choice in complex AIOD with contiguous involvement of the CFA.