Severe Aortoiliac Occlusive Disease Research Articles

Extra-anatomic bypass procedures for severe aortoiliac occlusive disease-A cohort study.

Extra-anatomic bypass (ExAB) grafting has been questioned due its inferior durability compared to anatomic bypass for aortoiliac occlusive disease (AIOD). This study aims to present early and late outcomes of patients treated with ExAB as well as to evaluate potential prognostic factors. This is a retrospective cohort study presenting a series of patients treated with ExAB for AIOD. All patients were treated between 2005 and 2022 within the Vascular Surgery Unit of a University Surgery Clinic. Both early (30-day) and late outcomes were evaluated. Univariate and multivariate analyses were conducted for potential predictors. Kaplan-Meier curve was produced for long-term patency. A total of 41 patients were treated (85.3% males; mean age: 76.3 ± 4.2years). Indication for treatment included severe claudication or critical limb ischemia (Rutherford stages III-VI). The following procedures were recorded: Femorofemoral bypass (FFB; n = 21) and axillofemoral bypass (AxFB; n = 20). All procedures were conducted using synthetic grafts with external rings. Early outcomes included no death, no myocardial infarction, no major bleeding, no graft infection, and no major amputation. Regarding late outcomes, 14.6% patients were lost after the first month. For the rest of patients (n = 35), five-year primary patency was 88.6%, primary-assisted patency was 94.3%, and secondary patency was also 94.3%. Limb salvage was 100% within follow-up. Endarterectomy at the distal anastomosis was the only independent predictor associated with worse patency in the long-term (OR = 5.356; 95% CI (1.012-185.562); p = .041). FFB and AxFB is a safe and durable strategy for treating patients with severe AIOD where no other option is feasible. Regarding predictors, only endarterectomy at the distal anastomosis site was associated with an increased risk for graft failure.

Long-Term Results of Thoracofemoral Bypass in the Initial Treatment of Juxtarenal Total Aortic Occlusion

Thoracofemoral bypass has been applied mostly secondary to previous procedures in the treatment of aortoiliac occlusive disease. However, its application as an initial treatment is less common, and long-term outcomes remain uncertain. The aim of this analysis was to review the 16-year experience and long-term outcomes of 31 consecutive patients who underwent thoracofemoral bypass as the primary procedure. All patients who underwent thoracofemoral bypass for severe aortoiliac occlusive disease between 2005 and 2021 were retrospectively analyzed. The occlusion and calcified plaques of the abdominal aorta at the renal level were common characteristics of all patients. The patients were divided into 2 groups: severe claudication group (Rutherford III group) and chronic limb-threatening ischemia group (Rutherford IV-V). Chi-square test or Fisher's exact test was used to compare categorical variables between the groups, and t-test or Mann-Whitney U-tests were used to compare continuous variables according to their distributions. The Kaplan-Meier curve was used to depict the time-to-event data. Thirty-one patients [age: 62 (56-67.5); male: 87%] underwent thoracofemoral bypass. Among the 31 patients, 21 (67.7%) belonged to the severe claudication group (Rutherford III), while 10 (32.3%) were in the chronic limb-threatening ischemia (Rutherford IV-V). Twenty-two patients (83.8%) remained asymptomatic after thoracofemoral bypass. The mean follow-up duration was 79±32months. The 30-day mortality rate was 3.2% (n=1). Major complications were observed in 9.6% of patients (n=3; respiratory: 6.4%, retroperitoneal hematoma: 3.2%). No significant difference was found between the claudication and chronic limb-threatening ischemia groups regarding major complications (3.2% vs. 6.4%, P=NS). Minor complications occurred in 41.9% of patients, including pleural effusion 9.6% (n=3), acute kidney injury 9.6% (n=3), gastrointestinal bleeding 3.2% (n=1), paralytic ileus 6.4% (n=2), and superficial skin infection 12.9% (n=4). The rate of postoperative superficial skin infection was higher in the chronic limb-threatening ischemia group compared to the claudication group (4 [40%] vs. 0 [0%], P: 0.007). The univariable Cox regression analysis revealed that hypertension and diabetes mellitus were not related to primary patency of the thoracofemoral bypass graft. The 5-year Kaplan-Meier estimated primary patency for the entire study was 96%±7% (95% confidence interval [CI]: 88.6-100), and the secondary patency was 96.3%±6% (95% CI: 89.4-100). The 5-year Kaplan-Meier estimated survival rate after thoracofemoral bypass was 93.4%±3 (95% CI: 91-100). We demonstrated in this study that thoracofemoral bypass can yield good outcomes when preferred as the initial treatment in selected patients with juxtarenal total aortic occlusion. Despite being a complex surgical technique, thoracofemoral bypass has shown to have safe, acceptable mortality and morbidity rates, as well as excellent long-term follow-up results in selected patients.

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.

Outcome of covered stents for severe aorto-iliac occlusive disease (AIOD) in patients with chronic limb-threatening ischaemia

Objective: To determine early and medium-term outcomes in patients with chronic limb-threatening ischaemia (CLTI) due to Transatlantic Inter-Society Consensus (TASC) C/D aorto-iliac occlusive disease (AIOD) treated with covered stents (CS). Design: A retrospective single-centre case series. Methods: Analysis of consecutive patients treated with CS for TASC C/D AIOD and CLTI between 2006 and 2017. The primary outcome was amputation-free survival (AFS). Secondary outcomes were survival, major limb amputation (MLA), patency, complications and freedom from re-intervention. Results: Eighty-eight patients (61 men; 7 TASC C; 81 TASC D) were treated for CLTI (54 rest pain; 34 tissue loss). One hundred and twenty limbs were revascularised with 99.8% technical success. The 30-day mortality was 4.5%. Postoperative complications occurred in 30 (34%) patients. Seven (8%) patients underwent MLA. AFS was 76.0% (95% CI 65.6 to 83.6) and 66.6% (95% CI 55.2 to 75.7), primary patency 83.9% (95% CI 71.0 to 91.4) and 70.5% (95% CI 52.8 to 82.6), and freedom from re-intervention 92.4% (95% CI 83.8 to 96.5) and 83.2% (95% CI 71.2 to 90.5) at 1 and 3 years, respectively. MLA was not associated with target lesion revascularisation (OR 4.35, 95% CI 0.89 to 21.18, p=0.073) or CS patency (OR 0.33, 95% CI 0.03 to 3.43, p=0.360). Age (HR 1.10, 95% CI 1.05 to 1.14, p<0.001), creatinine (HR 1.01, 95% CI 1.00 to 1.02, p<0.001), urgency (emergency: HR 3.10, 95% CI 0.97 to 9.98, p=0.057; urgent: HR 3.71, 95% CI 1.25 to 10.97, p=0.018), tissue loss (HR 5.34, 95% CI 2.36 to 12.07, p<0.001), postoperative respiratory complications (HR 5.37, 95% CI 1.44 to 20.01, p=0.012), congestive cardiac failure (HR 0.23, 95% CI 0.05 to 0.99, p=0.049) and implantation of bilateral CS (HR 0.38, 95% CI 0.15 to 0.94, p=0.036) were independently associated with AFS. Conclusions: Covered stents in patients with TASC C/D AIOD presenting with CLTI are associated with acceptable early and medium-term outcomes in these multi-morbid patients with reduced life expectancy. CS patency was not associated with MLA or AFS and may therefore represent a poor surrogate endpoint for assessing the efficacy of endovascular intervention for AIOD.

Successful Open Thoracoabdominal Aortic Repair in a Patient with Severe Aorto-Iliac Occlusive Disease: A Rare Case Report.

Open repair of thoracoabdominal aortic aneurysm (TAAA) in a patient with severe aorto-iliac occlusive disease is considered to cause an extremely high risk for spinal cord injury. A 71-year-old man who had previously undergone axillo-bifemoral bypass for aorto-iliac occlusive disease presented with persistent dilation of a TAAA. Using distal perfusion via partial extracorporeal circulation at mild hypothermia, we performed segmental sequential repair of Crawford type II TAAA. Various efforts were made to avoid spinal cord injury and ischemic visceral organ damage. Consequently, the patient completely recovered without any serious complications.

Extra Anatomic Aorto-Iliac Revascularization Using Descending Thoracic Aorta to Bifemoral Bypass in Selected Cases

When best medical treatment fails to relieve symptoms of aorto-iliac occlusive disease, endovascular treatment or conventional open surgery are the remaining optionsdepending on lesions and patients' characteristics. However, in certain situations bothendovascular tools and abdominal aorta to bifemoral bypass (TFB) are not an option and the use of the descending thoracic aorta may be considered as an inflow site for revascularization. This work is a single-center retrospective study. Between 2008 and 2020, 27 patients were identified who were treated with descending thoracic aorta to TFB for severe aorto-iliac occlusive disease. Primary end point was 30-day postoperative mortality and major cardiovascular events. Secondary end points were primary patency, secondary patency, and all-cause mortality. The mean age of patients was 68years and the majority (88.9%) presented with severe claudication. Eighteen patients underwent isolated TFB and 9 had TFB and concomitant visceral vessel revascularization. The mean length of stay was 14days and there was no postoperative death. Complications, mainly pulmonary, occurred in 29.8% of the cases. After a mean of 26months of follow-up, survival rate was 95% and primary and secondary patency rates were 92.6% and 96.3%, respectively. Mean Rutherford index shifted from 3.1 to 1.2 (P<0.001). TFB is an invasive procedure which provides high clinical improvement and patency rates. This procedure should remain part of the vascular surgeon portfolio.

Combination of Fenestrated Endovascular Aortic Repair With Distal Unibody Anatomic Fixation

Standard fenestrated endovascular aortic repair (FEVAR) necessitates caudal extension using a distal bifurcated module, which can be difficult with severe aortoiliac occlusive disease or a small terminal aorta. We have described our experience with a distal-first sequence, beginning with an anatomically fixed bifurcated unibody.

Editor's Choice – Covered vs. Bare Metal Stents in the Reconstruction of the Aortic Bifurcation: Early and Midterm Outcomes from the COBRA European Multicentre Registry

To report outcomes following endovascular revascularisation for severe aorto-iliac occlusive disease (AIOD) using covered (CS) or bare metal (BMS) stent(s). This was a retrospective cohort study including patients who underwent treatment with CS or BMS for AIOD between November 2012 and March 2020 in 12 European centres. Outcome measures included death, freedom from target lesion revascularisation (TLR), major amputation, and major adverse cardiac and cerebrovascular events (MACCE). Overall, 252 patients (53% males; mean age 65 ± 10 years) were included (102 with a bare metal and 150 with a covered aortic stent); 122 (48%) presented with chronic limb threatening ischaemia (CLTI). Severe arterial calcification was noted in > 65% of patients, 70% presented with Trans-Atlantic Societies Consensus (TASC) D lesions, 32% and 46% had aortic or iliac chronic total occlusion (CTO), respectively. Median follow up was 17 months (range 6 - 40; none lost to follow up). Median inpatient stay was two days (range two to four). During the first 30 days, two patients died (both with covered aortic stents, because of cardiovascular events), none required TLR, two (1%) patients had a major amputation (all presented with CLTI), and three (1%) had a MACCE. At 17 months, mortality (BMS 14% vs. CS 7%, hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.42 - 2.26, p= .94, log rank test) and TLR (11% vs. 10%, HR 1.98, 95% CI 0.89 - 4.43, p= .095) did not differ statistically significantly between the two groups; only three patients had a major limb amputation during late follow up (all with a covered stent). In a multivariable model, the use of an aortic CS did not influence TLR. In a conditional Cox regression, however, the concomitant use of aortic and iliac CSs was associated with improved freedom from TLR. Endovascular reconstruction with aortic CSs or BMSs for severe AIOD showed comparable midterm performance. The use of both aortic and iliac CSs seems to be associated with reduced TLR.

Endovascular Repair of Narrow Distal Aortas Using an In Situ Fenestration Technique

PurposeTo demonstrate that in situ fenestration (ISF) of an aorto-uni-iliac endograft to treat aortoiliac disease with narrow distal aorta (NDA) vessels is effective and safe. Materials and MethodsData for all patients treated by use of ISF between August 2014 and December 2019 were retrospectively analyzed. The series included 27 patients, aged 70 years ± standard error (SE) 11. The pathologies treated included aortoiliac occlusive disease (n = 16), asymptomatic abdominal aortic aneurysm (n = 8), and a ruptured abdominal aortic aneurysm (n = 3). The technique consisted of deploying an aorto-uni-iliac graft, which was converted into a bifurcated repair through contralateral iliac ISF. The inclusion criteria encompassed the presence of an abdominal aortic aneurysm (diameter of >50 mm, rapid growth, ruptured or symptomatic) associated with NDA or the presence of severe aortoiliac occlusive disease with NDA. NDA is defined as an aortic diameter of <16 mm. ResultsThe mean aortic bifurcation diameter was 11.9 mm ± SE 1.5. In total, 55% of the fenestrated endografts were performed with a multifilament polyester endograft and 45% with expanded polytetrafluoroethylene endograft. Technical success was 100%. Fluoroscopy time was 28 minutes ± SE 12, and 94 mL ± SE 43 of iodinated contrast medium was used. In the postoperative course, a single minor retroperitoneal hematoma was identified. The mean hospital stay was 5 days ± SE 3. At the mean follow-up of 26 months ± SE 22, overall primary patency was 94% and no endoleak was observed at the ISF site. ConclusionsThe ISF technique is safe and effective in the treatment of aortoiliac disease with NDA. Comparisons with alternative techniques are needed to determine the long-term durability.

Comparison of Aortobifemoral Bypass to Aortoiliac Stenting with Bifurcation Reconstruction for TASC II D Aortoiliac Occlusive Disease

Long-segment stenting of the infrarenal aorta and bilateral iliac arteries, with or without femoral endarterectomy for diffuse disease, has been adopted for treatment of severe aortoiliac occlusive disease (AIOD). The objective of this study was to compare outcomes of this reconstruction, termed aortoiliac stenting with bifurcation reconstruction (AISBR), to aortobifemoral bypass (ABF) in patients with comparable TASC II D lesions. This is a single-center, retrospective review of patients treated with ABF or AISBR for comparable TASC II D lesions between 2010 and 2018. ABF patients were included only if they were deemed anatomic candidates also for AISBR after review of preoperative imaging. Patients treated for acute limb ischemia and bypass graft infection were excluded. Statistics included Fisher exact test, Kaplan-Meier analysis, and Cox proportional hazards regression. There were 24 ABF and 75 AISBR included in the study. The primary indication for treatment was claudication in 55 (55.6%) patients, rest pain in 28 (28.3%), and tissue loss in 16 (16.2%). Patients undergoing AISBR were more likely to be female. Femoral endarterectomies were performed in 37/75 (49.3%) AISBR and 14/24 (58.3%) ABF (P=0.44). AISBR were performed percutaneously in 34/75 (45.1%). No AISBR required conversion to ABF. Intraoperative blood loss, procedure time and hospital length of stay (LOS) were significantly less for AISBR compared to ABF. Surgical site infections (SSI) were less common in patients undergoing AISBR (AISBR: 6/75 (8.0%) vs. ABF: 9/24 (37.5%), (P< 0.01). One AISBR and two 2 ABF developed late SSI >30 days postoperatively. The reductions in blood loss, LOS and SSI remained significant after excluding percutaneous AISBR from the analysis. Five-year primary patency was 50.8% (95% CI: 33.3, 68.4%) for AISBR and 88.1% (72.7, 100.0%) for ABF (P= 0.04). Five-year survival was 76.5% (95% CI: 63.6, 89.5) for AISBR and 100% (95% CI: 100.0, 100.0) for ABF (P=0.07). Five-year primary assisted patency, secondary patency, freedom from reintervention and major adverse limb events did not differ significantly between groups. AISBR is a viable option for management of TASC II D AIOD, with lower morbidity and acceptable durability when compared to traditional ABF.

Slaying Monster with Catheter: A Case Report

This is a case of successful treatment of secondary hypertension with catheter intervention in a 62 years old gentleman who has severe aortoiliac occlusive disease, severe coronary artery disease and other comorbidities. Early recognition, diagnosis and treatment of secondary causes of hypertension lead to good clinical outcomes, possible reversal of end-organ damage and better blood pressure control. Blood pressure control is essential prior to coronary intervention in patients with resistant hypertension and concomitant coronary artery disease to prevent haemorrhagic stroke and other unwanted complications. This gentleman has triple vessels and left main stem disease which surgeons refused for coronary artery by pass graft (CABG) in view patient has severe aorto-iliac occlusive disease with resistant hypertension. We have done successful revascularization to aorto-iliac followed by coronary intervention. Keywords secondary/resistant hypertension, coronary artery disease, aortoiliac occlusive disease, catheter (endovascular) intervention

Kissing Intravascular Balloon Lithoplasty and Endovascular Aortic Repair as a Treatment of Severe Distal Aorto-Iliac Occlusive Disease to Ensure a Safe Conduit to Facilitate Thoracic Endovascular Aortic Repair

We describe a novel case of treating severe distal aorto-illiac occlusive disease and endovascular aortic repair with kissing endoluminal lithoplasty balloons. This ensured a safe conduit to facilitate thoracic endovascular aortic repair.

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

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.

Contemporary outcomes of thoracofemoral bypass

ObjectiveThoracofemoral bypass (TFB) is an alternative to aortofemoral bypass (AFB) or extra-anatomic bypass for severe aortoiliac occlusive disease (AIOD). TFB may be particularly useful in select patients with concurrent visceral aortic branch vessel disease, infrarenal aortic occlusions, or after failed AFB. However, there are few contemporary series describing the indications and outcomes for TFB. Therefore, the purpose of this analysis was to review our experience with TFB. MethodsAll patients undergoing TFB for occlusive disease from 2002 to 2017 were reviewed. All patients underwent left thoracoretroperitoneal exposure of the supraceliac aorta with division of the diaphragmatic crus and supraceliac cross-clamping. An end-to-side aortic anastomosis was created and each graft limb was tunneled in the retroperitoneum to the femoral bifurcation. Adjunctive visceral/infrainguinal revascularization was performed selectively based on symptoms, end-organ function, and/or preoperative imaging. The primary end points were major complications and 30-day mortality. Secondary end points included limb patency, freedom from major adverse limb events, and survival. Kaplan-Meier methodology was used to characterize the end points. ResultsForty-one patients (age 61 ± 9 years; 54% female; 7% in a hypercoaguable state) underwent TFB. The mean preoperative ankle-brachial index was 0.4 bilaterally. Indications included critical limb ischemia (56%), claudication (30%), acute limb ischemia (7%), and combined AIOD and mesenteric ischemia (7%). Seven patients (17%) had previously undergone AFB and 15 (38%) had previously undergone any prior aortic operation. Adjunctive visceral bypass occurred in 8 patients (20%; N = 14 grafts, n = 6 renal, n = 5 superior mesenteric artery, and n = 3 celiac). The postoperative duration of stay was 11 days (interquartile range [IQR], 7-16 days) and the 30-day mortality was 5% (n = 2). Major complications occurred in 34% of patients (N = 14; pulmonary, 15%; cardiac, 12%; bleeding, 7%; accidental splenectomy, 5%; renal, 5%; wound, 2%). The mean postoperative ankle-brachial index was 0.9 bilaterally. At a median follow-up of 7 months (IQR, 1-17 months), 5 patients (12%) underwent some form of reintervention (graft/limb related, n = 4 [n = 2 graft thrombosis, n = 2 graft infection], n = 1 mesenteric bypass revision). The estimated 3-year primary limb patency and freedom from major adverse limb events were 80 ± 10%, and 70 ± 10%, respectively. The estimated 5-year survival was 93 ± 5% (median, 27.3; IQR, 14.5-35.2; 95% confidence interval, 17.9-32.8). ConclusionsThis experience represents one of the largest and most current series of retroperitoneal TFB. We demonstrate that TFB can be performed with good outcomes for patients with severe AIOD, especially if concomitant visceral/infrainguinal reconstruction is warranted. These results support a continued role for TFB in select patients.

Minimally Invasive Management of Severe Aortoiliac Occlusive Disease.

Peripheral arterial disease (PAD) is a complex and highly prevalent pathology. It has been estimated that ∼8.5 million people in the United States are affected by PAD, of which 12%-20% are older than age 60. The TransAtlantic Inter-Society Consensus (TASC) guidelines classified aortoiliac atherosclerotic disease based on morphology and level of lesions. TASC II guidelines recommend bilateral surgical bypass to the femoral arteries for TASC II C and D lesions. The aortobifemoral bypass (ABF) has been considered the gold standard in the treatment of aortoiliac occlusive disease (AIOD). The long-term patency rate of 85%-90% at 5 years and 75%-80% at 10 years has been for a long time unmatched by other methods of revascularization. This is a review of the current literature regarding minimally invasive strategies in the care of TASC II C and D aortoiliac disease. Endovascular therapies have led to a paradigm change even in the treatment of highly advanced lesions. Reconstruction of the aortic bifurcation for distal aortic and/or ostial unilateral/bilateral common iliac artery disease can be achieved via the deployment of stents with "kissing" technique and aortic endografts. Laparoscopic aortoiliac surgery for TASC II C and D lesions was first proposed in 1993. Total laparoscopic, laparoscopic-assisted, and laparobotic techniques have been described. Minimal incision aortic surgery (MIAS) describes abdominal incisions varying from 6 to 12 cm and positional adjustment of retractors to access the retroperitoneum for infrarenal aortic aneurysms and/or AIOD. Although initial enthusiasm laparoscopic aortic surgery and MIAS have failed to gain acceptance in the vascular surgery community due to intrinsic procedural challenges, they are currently practiced in few highly specialized centers. At this moment, high-quality evidence is lacking regarding the further feasibility of these techniques and their applicability in general practice compared to endovascular therapies. While the ABF remains still the optimal choice in select, fit for surgery patients, endovascular therapies offer a less invasive approach that may provide a mortality and morbidity benefit in higher risk patients with acceptable short- and long-term outcomes.

The outcome of treatment of Trans-Atlantic Inter-Society Consensus D aortoiliac disease

Objective The long-term durability of the open bypass is better than that of endovascular treatment (EVT) for Trans-Atlantic Inter-Society Consensus (TASC) D aortoiliac lesions, but many recently developed devices and a variety of access options have increased the success rates of EVT, with less operative mortality and complication rates. In this study, we aimed to compare the technical success rates, primary patency rate, clinical outcomes, and complication for TASC D aortoiliac lesions treated by endovascular and surgical procedures. Patients and methods Data from 89 patients with chronic iliac artery stenosis and/or occlusion who were treated with endovascular or surgical treatment were retrospectively reviewed in the period between January 2003 and December 2017. Results The procedure time was longer for the surgical group than for the EVT group. The total complication rate was higher in the surgical group than in the EVT group. The mortality rate associated higher with the surgical group. There was no statistically significant difference between the groups regarding 2-year primary patency rates. Conclusion This study revealed that patients with severe aortoiliac occlusive disease (TASC D) can be treated with EVT or surgically with satisfactory results, with better technical success in the surgical group than in the EVT group. Furthermore, the 2-year patency rate for both groups was acceptable.

Comparison of Direct and Less Invasive Techniques for the Treatment of Severe Aorto-Iliac Occlusive Disease

Severe aorto-iliac occlusive disease (AIOD) is traditionally treated with aorto-bifemoral bypass (ABF) or aorto-unifemoral bypass (AUF). However, cross-femoral bypass(CFB) and hybrid femoral endarterectomy and patch angioplasty with iliac stenting (EPS) have gained popularity as less invasive options. We sought to compare 1-year survival, primary patency, and major amputation rates between open surgical (ABF and AUF) and 2 less invasive reconstruction techniques (CFB and EPS) using a large, multicenter cohort. This is a retrospective cohort study of patients who underwent either ABF/AUF or CFB/EPS for AIOD between 2006 and 2013 in the Society for Vascular Surgery Vascular Quality Initiative registry. Baseline patient and periprocedural variables were compared. Propensity score matching (PSM) was performed to predict the likelihood of more invasive repair. Kaplan-Meier analysis and Cox models were performed for 1-year survival, primary patency, and major amputation. 1872 patients underwent procedures for AIOD, including 1,133 ABF/AUF and 739 CFB/EPS, during the study period. Indication was critical limb ischemia in 47.3% (n=886). Median follow-up time was 305days (range, 10-406). After PSM, the matched cohort included 1,094 ABF/AUF and 711 CFB/EPS patients. Multivariate analysis revealed that patient factors and procedure indication were significant predictors of 1-year mortality and major amputation, but not procedure type. ABF/AUF was associated with improved primary patency over CFB/EPS at 1 year (94.1%±1.1% vs. 92.3%±1.5%, hazard ratio 0.65, 95% confidence interval 0.45-0.94; P=0.02). In a propensity-matched cohort from a multicenter vascular surgery registry, a direct approach to AIOD (ABF/AUF) demonstrated better 1-year primary patency than commonly used less invasive strategies. However, treatment approach was not a predictor of 1-year survival or limb salvage, suggesting that patient factors and procedure indication have a greater impact on outcome.

FT15. Endovascular vs Open Treatment of Severe Aortoiliac Occlusive Disease: Outcomes of Kissing Self-Expanding Covered Stent for Reconstruction of the Aortic Bifurcation

FT15. Endovascular vs Open Treatment of Severe Aortoiliac Occlusive Disease: Outcomes of Kissing Self-Expanding Covered Stent for Reconstruction of the Aortic Bifurcation

Perioperative humoral stress response to laparoscopic versus open aortobifemoral bypass surgery

Minimally invasive surgery seems to reduce hormonal stress response to surgery, but has not previously been examined in major abdominal vascular surgery. Aortic cross-clamping time and operation time is known to be longer in the totally laparoscopic aortobifemoral bypass (LABF) as compared to open aortobifemoral bypass (OABF). The main objective of our study was to measure the hormonal stress response during surgery and aortic cross-clamping in patients undergoing a totally laparoscopic versus an open aortobifemoral bypass. This was a sub-study of a larger randomized controlled multicentre trial. Thirty consecutive patients with severe aortoiliac occlusive disease were randomized to either a laparoscopic (LABF) or an open (OABF) procedure. The surgical stress response was measured by perioperative monitoring of adrenocorticotropic hormone (ACTH), aldosterone, metanephrine and cortisol at eight different time-points. During surgery. there was an increase in all humoral stress markers in both groups. The analysis of covariance showed increased levels of cortisol and ACTH in open group at 24 h time-point as compared to the baseline and this difference was statistically significant between the two groups, which indicate an earlier return to baseline levels in the laparoscopic group. Results from the General Estimated Equations (GEE) model indicate that LABF generates a lower level of metanephrine and higher level of aldosterone as compared to OABF. In conclusion, although they have higher levels of ACTH, aldosterone and cortisol during surgery, the patients operated with a laparoscopic aortobifemoral bypass achieve earlier hormonal homeostasis after surgery compared to open aortobifemoral bypass.