The aim of this study was to compare open repair (OR) vs endovascular repair (ER) using covered stents for TransAtlantic Inter-Society Consensus (TASC) C and D aortoiliac obstructive lesions in patients at low surgical risk and in young patients. A single-center retrospective review of TASC C and D iliac lesions treated between January 2008 and November 2017 was conducted. The 30-day outcomes, long-term patency, limb salvage, and freedom from related reintervention were compared between OR an ER. Low surgical risk was defined as Society for Vascular Surgery comorbidity score of 0.7 and age 75 years. A subanalysis was performed in patients considered young (age, 60 years). Follow-up results were analyzed with Kaplan-Meier curves. Major clinical and anatomic characteristics were evaluated for their association with patency in the two groups using Cox proportional hazards. Overall, 112 patients (OR, n = 56; ER, n = 56) were treated, with 63% having bilateral iliac disease involvement (n = 70 patients) for a total of 182 limbs revascularized (OR, n = 96; ER, n = 86). Iliac lesions were classified by limb as TASC C (n = 51 [28%]) and D (n = 131 [72%]). Mean age was 61.6 ± 8.4 years, with a mean Society for Vascular Surgery comorbidity score of 0.51 ± 0.39, without differences between OR and ER (0.440.29 vs 0.560.47; P = .20). At 30 days, the ER group compared with the OR group was characterized by shorter length of hospitalization (6.28.2 vs 8.56.2 days; P < .001) and intensive care unit stay (0.10.6 vs 0.90.5 days; P < .001); the cumulative medical (OR, 7%; ER, 5%; P = 1.0) and surgical (OR, 6%; ER, 3%; P = .11) complication rates were similar. At 5 years, primary patency was similar between the two groups (OR, 87.3%; ER, 81.4%; P = .31; Fig), and this result was confirmed in the subgroup of young patients (OR, 84.7; ER, 75.0; P = .27). Limb salvage (OR, 98.9%; ER, 98.4%; P = .91) and freedom from related reintervention (OR, 76%; ER, 72.9%; P = .24) were similar; this trend was confirmed also in young patients for both limb salvage (OR, 98.5%; ER, 97.6%; P = .83) and freedom from related reintervention (OR, 76.9%; ER, 63.6%; P = .10). Multivariate analysis indicated that the only independent negative predictor of patency was the sex (female) undergoing ER with covered stent (hazard ratio, 2.89; 95% confidence interval, 1.45-26.60; P = .024; Table). In case of severe aortoiliac obstructive lesions in low-risk and young patients, ER using covered stent may be considered as valid as OR because it allows shorter hospitalization after the procedure, maintaining similar patency during long-term follow-up. However, in female patients, OR still remains the “gold standard” of treatment.TableCox proportional hazards for primary patency in the 182 limbs treated with open (OR) or endovascular (ER) revascularizationHR95% CIPTASC D1.510.42-5.36.520Bilateral disease2.550.67-9.68.166ER0.890.18-3.59.781Female sex0.490.06-4.00.507ER + female sex2.891.45-26.60.024aCI, Confidence interval; HR, hazard ratio; TASC, TransAtlantic Inter-Society Consensus.aStatistically significant. Open table in a new tab