Treatment Of Aortoiliac Occlusive Disease Research Articles

Case Report: Endovascular approach with kissing stent technique in aortoiliac occlusive disease (Leriche syndrome) patient

Background: Aortoiliac occlusive disease (AIOD) or Leriche syndrome, is a peripheral artery disease, specifically affecting the infrarenal aorta and iliac arteries. Presentation of AIOD patients ranged from asymptomatic to having limb-threatening emergencies. Advances and innovations in endovascular devices have replaced surgical approach for AIOD treatment. Here we reported a 52-year-old man presenting with AIOD managed by endovascular approach using kissing stent technique. Case presentation: A 52-year-old man, with history of chronic coronary artery disease, diabetes mellitus type 2, long-standing hypertension, and who was a heavy smoker, was admitted to our hospital with symptoms of long time with bilateral claudication and became leg rest pain. He had history of aorto-infrarenal occlusion known from previous percutaneous coronary intervention from right and left femoral artery access. Aortoiliac occlusive disease (TASC II Type D Class) diagnosis was made by lower extremity duplex ultrasound and CT angiography. The patient underwent urgent percutaneous transluminal angioplasty with kissing stent technique. The patient was discharged 4 days after the procedure without any significant complaints, received optimal medical treatment, and was educated about smoking cessation. Conclusion: Treatment of AIOD should include both modification of risk factors and efforts to increase perfusion to the lower extremities. An endovascular approach is an excellent alternative and may replace surgical approach in complex aortoiliac obstructive disease. In this case report, an endovascular approach with kissing stent technique showed good results for the patient.

Single Tract Aortic Revascularization Technique in the Treatment of Aortoiliac Occlusive Disease

Single Tract Aortic Revascularization Technique in the Treatment of Aortoiliac Occlusive Disease

Long-Term Patency of Stent Angioplasty for Aortoiliac Occlusive Disease: A Literature Review

Introduction. Surgical revascularization remains a definitive therapy for aortoiliac occlusive disease. Revascularization could be achieved via endovascular treatment using angioplasty or open surgery. A limited number of studies currently assess the long-term patency of stent angioplasty of aortiliac occlusive disease. This study aims to evaluate or find recent evidence regarding the evaluation of the long-term patency of stent angioplasty for the treatment of aortoiliac occlusive disease. Method. Literature searching was conducted through several online databases, including Cochrane, PubMed, and EBSCOHost. Several cohort and randomized controlled studies assessing long-term patency of stent angioplasty ranging from bare metal stent to balloon angioplasty published from 2010 to 2022 were included. Critical appraisal was conducted using the Oxford Centre of Evidence-Based Medicine checklist. Results. Initial database searching yielded 26 published titles, of which 21 were excluded based on our inclusion-exclusion criteria and being a duplicate. Five studies, consisting of five cohort studies and one systematic review, were included. Long-term primary, assisted-primary, and secondary patency data were acquired in each study. Conclusion. We found heterogeneous data regarding long-term patency in each study. We found that 60-month primary patency ranges from 74.7% - 83.9%, assisted primary patency ranges from 83.7% - 95.8%, and secondary patency ranges from 92.8% - 99%. Overall, endovascular therapy by angioplasty has proven satisfactory long-term patency over five years.

Aortobifemoral bypass vs covered endovascular reconstruction of aortic bifurcation

BackgroundCovered endovascular reconstruction of aortic bifurcation (CERAB) is increasingly used as a first line-treatment in patients with aortoiliac occlusive disease (AIOD). We sought to compare the outcomes of patients who underwent CERAB compared with the gold standard of aortobifemoral bypass (ABF). MethodsThe Vascular Quality Initiative was queried for patients who underwent ABF or CERAB from 2009 to 2021. Propensity scores were generated using demographics, comorbidities, Rutherford class, and urgency. The two groups were matched using 5-to-1 nearest-neighbor match. Our primary outcomes were 1-year estimates of primary patency, major adverse limb events (MALEs), MALE-free survival, reintervention-free survival, and amputation-free survival. Standard statistical methods were used. ResultsA total of 3944 ABF and 281 CERAB cases were identified. Of all patients with AIOD, the proportion of CERAB increased from 0% to 17.9% between 2009 and 2021. Compared with ABF, patients who underwent CERAB were more likely to be older (64.7 vs 60.2; P < .001) and more often had diabetes (40.9% vs 24.1%; P < .001) and end-stage renal disease (1.1% vs 0.3%; P = .03). In the matched analysis (229 CERAB vs 929 ABF), ABF patients had improved MALE-free survival (93.2% [±0.9%] vs 83.2% [±3%]; P < .001) and lower rates of MALE (5.2% [±0.9%] vs 14.1% [±3%]; P < .001), with comparable primary patency rates (98.3% [±0.3%] vs 96.6% [±1%]; P = .6) and amputation-free survival (99.3% [±0.3%] vs 99.4% [±0.6%]; P = .9). Patients in the CERAB group had significantly lower reintervention-free survival (62.5% [±6%] vs 92.9% [±0.9%]; P < .001). Matched analysis also revealed shorter length of stay (1 vs 7 days; P < .001), as well as lower pulmonary (1.2% vs 6.6%; P = .01), renal (1.8% vs 10%; P < .001), and cardiac (1.8% vs 12.8%; P < .001) complications among CERAB patients. ConclusionsCERAB had lower perioperative morbidity compared with ABF with a similar primary patency 1-year estimates. However, patients who underwent CERAB experienced more major adverse limb events and reinterventions. Although CERAB is an effective treatment for patients with AIOD, further studies are needed to determine the long-term outcomes of CERAB compared with the established durability of ABF and further define the role of CEARB in the treatment of AIOD.

Efficacy and Safety of Covered Stents Versus Bare-Metal Stents for Aortoiliac Occlusive Disease: A Systematic Review and Meta-Analysis.

This study aimed to assess the efficacy and safety outcome of covered stents (CSs), as compared with bare-metal stents (BMSs), for the treatment of patients with aortoiliac occlusive disease (AIOD). A systematic literature search was conducted in PubMed, Embase, and Cochrane Library up to August 2023 to identify all studies comparing efficacy and safety outcomes of CSs versus BMSs for treating AIOD. Our outcome was primary patency, secondary patency, technical success, ankle-brachial index (ABI) variation, target lesion revascularization (TLR), limb salvage, complications, and long-term survival. Dichotomous outcomes were pooled as relative risks (RR) or hazard ratio with the 95% confidence interval (CI). Continuous outcomes were pooled as weighted mean differences and 95% CI. Model selection was based on the heterogeneity of the included studies. There were 10 studies (2 randomized controlled trials, 8 retrospective cohort studies), comprising 1676 sample size. Compared with BMSs, CSs use was associated with better primary patency of patients with a Trans-Atlantic Inter-Society Consensus II (TASC) D lesion (RR, 1.15, 95% CI, 1.04 to 1.27, p=0.007), TLR (RR, 0.39, 95% CI, 0.27 to 0.56, p<0.001), technical success (RR, 1.01, 95% CI, 1.00 to 1.02, p=0.010), and long-term survival (RR, 1.06, 95% CI, 1.01 to 1.11, p=0.020). There is no difference between CSs and BMSs regarding primary patency of all patients, secondary patency, variation in ABI, limb salvage, and complications. Compared with BMSs, CSs used in AIOD was associated with more favorable primary patency in patients with TASC D lesions, TLR, technical success rates, and patient long-term survival. These results provide evidence of the advantages of using CSs for AIOD treatment. Future studies focusing on long-term variations in ABI, primary patency of different degrees of calcification, vascular segments, and TASC classification are warranted. Although several studies evaluated the clinical efficacy of CS in the context of AIOD treatment, the significance and consistency of these findings were not determined to date. We found that CS was used in AIOD associated with better technical success rate, long-term patient survival, lower target lesion revascularization, and higher primary patency of patients with a Trans-Atlantic Inter-Society Consensus II D lesion when compared with BMSs. Our study provides evidence supporting the superiority of CSs over BMSs in the treatment of AIOD, and furnishing clinicians with guidance for treatment decisions.

10년간의 3차 의료기관 경험을 바탕으로 한 대동맥장골동맥 폐색 질환 혈관내 치료의 기술적 고찰: 후향적 연구.

To examine the technical considerations of endovascular treatment for aortoiliac occlusive disease (AIOD) based on a 10-year experience in Songklanagarind Hospital. This retrospective cohort study included 210 patients who underwent endovascular treatment for symptomatic AIOD between January 2010 and December 2020. The patients' clinical and lesion characteristics, including technical considerations of the procedure, were collected, analyzed, and stratified using the Transatlantic Inter-Society Consensus (TASC). Most patients (80%) in this study had chronic limb-threatening ischemia lesions, with an occlusion rate of 37%. The technical success rate of TASC C & D was lower than that of TASC A & B, 84.4% vs. 99.2% p ≤ 0.001. A technical success rate of 93.3% (14/15) was found for the femoral and brachial approach, compared with a success rate of 89.0% (57/64) for the unibifemoral approach in TASC C & D, without a statistically significant difference (p = 0.076). However, the puncture site complications in this route were up to 17.6%, which is the highest rate compared with other techniques. These complications could be treated either conservatively or minimally invasively. In cases of failed femoral access, simultaneous femoral and brachial approaches improved the technical success rate of endovascular recanalization of TASC C & D aortoiliac occlusions.

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.

Outcomes of covered vs bare metal stents for the treatment of aortoiliac occlusive disease

ObjectiveWe retrospectively compared the clinical outcomes of self-expanding covered stents (CSs) and bare metal stents (BMSs) in the treatment of aortoiliac occlusive disease (AIOD) at a single center between 2016 and 2022. MethodsAll patients with AIOD receiving endovascular therapy at a single center from January 2016 to October 2022 were continuously analyzed, including patients with lesions of all classes according to the Trans-Atlantic Inter-Society Consensus II (TASC-II). Relevant clinical and baseline data were collected, and propensity score matching was performed to compare CSs and BMSs in terms of baseline characteristics, surgical factors, 30-day outcomes, 5-year primary patency, and limb salvage. The follow-up results were analyzed by Kaplan-Meier curves. Cox proportional hazard models were used to identify predictors of primary patency. ResultsA total of 209 patients with AIOD were enrolled in the study, including 135 patients (64.6%) in the CS group and 74 patients (35.4%) in the BMS group. Surgical success rates (100% vs 100%; P = 1.00), early (<30-day) mortality rates (0% vs 0%; P = 1.00), cumulative surgical complication rate (12.0% vs 8.0%; P = .891), 5-year primary patency rate (83.4% vs 86.9%; P = .330), secondary patency rate (96% vs 100%; P = .570), and limb salvage rate (100% vs 100%; P = 1.00) did not exhibit significant differences between the two groups. Patients in the CS group had a lower preoperative ankle-brachial index (0.48 ± 0.26 vs 0.52 ± 0.19; P = .032), more cases of complex AIOD (especially TASC D) (47.4% vs 9.5%; P < .001), more chronic total occlusive lesions (77.0% vs 31.1%; P < .001), and more severe calcification (20.7% vs 14.9%; P < .036). After propensity score matching, 50 patients (25 with CS and 25 with BMS) were selected. The results showed that only severe calcification (32.0% vs 8.0%; P = .034) and ankle-brachial index increase (0.45 ± 0.15 vs 0.41 ± 0.22; P = .038) were significantly different between the groups. In terms of surgical factors, patients in the CS group had more use of bilateral femoral or combined brachial artery percutaneous access (60.0% vs 12.0%; P < .001), more number of stents used (2.3 ± 1.2 vs 1.3 ± 0.7; P < .001), longer mean stent length (9.3 ± 3.3 vs 5.8 ± 2.6 cm; P < .001), and more catheter-directed thrombolysis treatment (32.0% vs 4.0%; P = .009). Multivariate Cox survival analysis showed that severe calcification (hazard ratio, 1.32; 95% confidence interval, 1.04-1.85; P = .048) was the only independent predictor of the primary patency rate. ConclusionsAll patients with AIOD who underwent endovascular therapy were included and achieved good outcomes with both CSs and BMSs. The influence of confounding factors in the two groups was minimized by propensity score matching, and the 5-year patency rates were generally similar in the unmatched and matched cohorts. Postoperative hemodynamic improvement was more obvious in patients in the CS group. For more complex lesions, CS is recommended to be preferred. Especially for severe calcification lesions, which is the only independent predictor of primary patency, CS showed obvious advantages. Further studies with more samples are needed to investigate the role of stent types in AIOD treatment.

A sex-based analysis of 5-year outcomes following stenting for the treatment of aorto-iliac occlusive disease.

The aim of this study was to evaluate the impact of sex on mid-term outcomes following stenting for aorto-iliac occlusive disease (AIOD). The Covered versus Balloon Expandable Stent Trial (COBEST) compared the safety and efficacy of the covered stent (CS) with those of the bare metal stent (BMS) in the treatment of hemodynamically significant AIOD. It was identified that CS provided a significant benefit. The primary endpoint of our analysis was the rate of primary patency 5years following stenting for AIOD (inclusive of both CS and BMS) in both sexes. Of the 168 lesions treated, 103 (61%) were present in men and 65 (39%) were present in women. Of the concomitant comorbidities, diabetes mellitus was significantly more common in women (17.5% vs 41.5%, p = .006). Although chronic limb threatening ischemia (CLTI) at the time of intervention was more common in women, the difference was not significant (16.5% vs 24.6%, p = .395). Sex was not associated with the primary patency rate (male; 0.70, 95% confidence interval [CI]: 0.23-2.19, p = .543). When considering both male sex and the utilization of BMS, no significant impact was found on the primary patency rate (hazard ratio [HR]: 3.43, 95% CI: 0.69-17.10, p = .133). All-cause mortality at 60 months was 22.6% in men compared to 19.4% in women (p = .695). No significant difference was identified in the primary patency rate between the sexes. Further investigation is warranted to ascertain whether sex-specific interventional guidelines are required in this regard.

The Impact of Patient Sex on Outcomes after Endovascular Treatment of Aortoiliac Occlusive Disease

The aim of this study was to explore the effect of patient sex on short and long-term outcomes after endovascular treatment for aortoiliac occlusive disease (AIOD). A multi-center retrospective analysis was performed on all patients who underwent iliac artery stenting for aorto-iliac occlusive disease across the three participating sites from October 1, 2018 to September 21, 2021. Preoperative clinical, operative, and post-operative data were collected on a dedicated database. Demographics and outcomes were compared between male and female patients and the probability of freedom from amputation and freedom from target lesion reintervention were estimated with the Kaplan-Meier method. Of 574 patients, 346 (60%) were male and 228 (40%) were female. Mean follow-up was 12 months. Female patients were significantly older (69.2 ± 10.2 years vs. 67.8 ± 8.9 years, p=0.025) and more likely to have Trans-Atlantic Inter-Society Consensus (TASC II) D disease (p=0.003). The female cohort had significantly less coronary artery disease (40% vs. 50%, p=0.013), coronary stenting (14% vs. 21%, p=0.039), and coronary artery bypass grafting (13% vs. 25%, p < 0.001) than the male cohort, as well as less statin use (69% vs 80%, p=0.004). There were no differences in stent type, concomitant open surgery, intraoperative events or hospital length of stay. For 30-day post-operative complications, female patients had a significantly higher rate of thrombotic acute limb ischemia (2% vs. 0%, p=0.01), while male patients had a higher rate of amputation (4% vs. 9%, p=0.048). On mid-term outcomes, there was no difference in freedom from amputation or target lesion re-intervention between male and female patients (p=0.14, p=0.32 respectively). Female patients had lower incidence of cardiovascular risk factors but presented with higher TASC II classification and had higher rates of 30-day thrombotic acute limb ischemia. Male patients were more likely to require amputation within 30 days. Despite no differences in the mid-term, these short-term findings suggest that patient sex may be a relevant consideration in post-operative management and surveillance after endovascular treatment of AIOD.

Long-Term Outcomes of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique in Patients With Aorto-Iliac Occlusive Disease.

The Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) reconstruction is an endovascular technique, developed to reconstruct the aortic bifurcation in the most optimal anatomical and physiological manner. Short-term data were promising, but long-term data are still lacking. The objective was to report the long-term outcomes of CERAB for extensive aorto-iliac occlusive disease and to identify predictors for loss of primary patency. Consecutive electively treated patients with CERAB for aorto-iliac occlusive disease in a single hospital were identified and analyzed. Baseline and procedural data and follow-up were collected at 6-weeks, 6 months, 12 months, and annually thereafter. Technical success, procedural, and 30-day complications were evaluated, as well as overall survival. Patency and freedom from target lesion revascularization rates were analyzed using Kaplan Meier curves. Uni- and multivariate analysis were performed to identify possible predictors of failure. One hundred and sixty patients were included (79 male). Indication for treatment was intermittent claudication for 121 patients (75.6%) and 133 patients (83.1%) had a TASC-II D lesion. Technical success was obtained in 95.6% of patients and the 30-day mortality rate was 1.3%. The 5-year primary, primary-assisted, and secondary patency rates were 77.5%, 88.1%, and 95.0%, respectively, with a freedom-from clinically driven target lesion revascularization (CD-TLR) rate of 84.4%. The strongest predictor of loss of primary patency of CERAB was a previous aorto-iliac intervention (odds ratio [OR]=5.36 (95% confidence interval [CI]: 1.30; 22.07), p=0.020). In patients not previously treated in the aorto-iliac tract, 5-year primary, primary assisted, and secondary patency rates were 85.1%, 94.4%, and 96.9%, respectively. At 5-year follow-up, an improved Rutherford was found in 97.9% of patients and the freedom from major amputation rate was 100%. The CERAB technique is related to good long-term outcomes, particularly in primary cases. In patients that had prior treatment for aorto-iliac occlusive disease, there were more reinterventions and therefore surveillance should likely be more intense. The Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) reconstruction was designed to improve outcomes of endovascular treatment of extensive aorto-iliac occlusive disease. At 5-year follow-up clinical improvement was found in 97.9% of patients without major amputations. The 5-year overall primary, primary-assisted, and secondary patency rates were 77.5%, 88.1%, and 95.0%, respectively, with a freedom-from clinically driven target lesion revascularization rate of 84.4%. Significantly better patency rates were observed for patients that were never treated before in the target area. The data implicate that CERAB are a valid treatment option for patients with extensive aorto-iliac occlusive disease. For patients previously treated in the target area, other treatment options might be considered, or more intensive follow-up surveillance is warranted.

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.

Ten-year Experience with Endologix Afx Endograft for the Treatment of Aortoiliac Occlusive Disease

Ten-year Experience with Endologix Afx Endograft for the Treatment of Aortoiliac Occlusive Disease

Endovascular treatment of aorto-iliac occlusive disease with TASC II C and D lesions: 10 year’s experience of clinical technique

ObjectivesThe purpose of this study was to evaluate the therapeutic efficacy and safety of endovascular treatment aorto-iliac occlusive disease (AIOD) with TransAtlantic Inter-Society Consensus II (TASC II) C and D lesions. In addition, 10 years of experience with interventional procedures and treatment options in our center were also worthy of further discussion.MethodsBetween January 2011 and December 2020, a total of 26 consecutive AIOD patients with TASC-II C and D lesions treated endovascular approach were enrolled in this study. Patients' demographic and clinical data were collected, and the safety and efficacy of endovascular therapy were evaluated. In addition, operation procedures were also described.ResultsThe mean age of patients was 62.2 ± 7 years (49–57 years), and the mean body mass index of patients was 24.2 ± 2.6 kg/m2. Fifteen patients (57.7%) were Rutherford 4, 5 each (19.2%) were Rutherford 3 and 5, and 1 (3.8%) was Rutherford 2. No other serious complications occurred except death in 3 patients. Most of the patients (73.1%) had a history of smoking, and hypertension and hyperlipidemia were common comorbidities. Endovascular therapy was successfully performed in 25 patients, and the technical success rate was 96.2%. The patient's ankle-brachial index improved significantly postoperatively compared with preoperatively (preoperative 0.33 ± 0.14 vs 1.0 ± 0.09, P < 0.001). The primary patency rates were 100%, 95.7%, and 91.3% at 1, 3, and 5 years, while the secondary patency rates were 100%. No treatment-related deaths or serious complications occurred.ConclusionsEndovascular treatment of AIOD patients with TASC-II C and D lesions might be safe and have a high rate of middle-term and long-term primary patency.

Comparison of the Haemodynamic Performance of Various Treatment Options for Aorto-Iliac Occlusive Disease

Several surgical and endovascular techniques are used during the treatment of aorto-iliac occlusive disease. Aortobifemoral bypass (AoBFB) is the standard of care, but other options such as axillobifemoral (AxBFB) bypass, aorto-iliac kissing stents (KS), and covered endovascular reconstruction of aortic bifurcation (CERAB) are also available. This study aimed to perform a computational comparison of these four modalities to investigate their haemodynamic performance. Eight patient specific anatomies were analysed, with each of the abovementioned techniques used to treat two anatomies. The CT angiograms were segmented from the renal (or axillary) to common femoral arteries and the 3D geometries were exported. A commercial finite volume solver was implemented for numerical simulations. Outcomes that were assessed were pressure drop (ΔP) between the inlet and the outlet for every configuration and haemodynamic indices of Time Average Wall Shear Stress (TAWSS), Oscillatory Shear Index (OSI), and Relative Residence Time (RRT) as markers of a thrombogenic environment. The results indicate that maximum ΔP was observed at peak systole for all models, with values ranging between 12mmHg and 21mmHg for the AoBFB, 64mmHg and 96mmHg for the AxBFB, 31mmHg and 46mmHg for the KS, and 43mmHg and 46mmHg for the CERAB configuration. TAWSS, OSI, and RRT varied among different configurations, mostly presenting values well above thrombogenic thresholds. Regarding RRT, the percentage of total surface area presenting such values is 2.5%, 3.2%, 2%, and 4.3% for the AoBFB, AxBFB, KS, and CERAB configurations, respectively. Computational modelling indicates a favourable haemodynamic performance of AoBFB compared with the other configurations. This leads to a smaller pressure drop and sconsequently a higher pressure in the outlet of the conduit, which is the perfusion pressure of the limb. Notably, lower patency rates of the latter modalities cannot be explained based on haemodynamic indices.

Results of endovascular treatments of Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation.

The current study aims to report midterm results of patients treated with endovascular intervention, kissing stent, or covered endovascular reconstruction of the aortic bifurcation, for Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation. Eighteen patients who have intermittent claudication or chronic limb threatening ischemia with Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation enrolled to the study between January 2018 and January 2021. Kissing stents, Advanta V12 (Atrium, Getinge Group), were used in 13 patients, and the covered endovascular reconstruction of the aortic bifurcation technique was used in 4 patients to reconstruct the aortic bifurcation. The patients were followed for a median of 49 months (min. 2, max.58 months). Patency rates, mortality, morbidities, and reinterventions were recorded. The mean age of the patients was 60.4 ± 10 years. Technical success was achieved in 94.4% of the patients, but one patient had to convert to open surgery. Primary patency rate of the remaining patients was 85.6% at 58 months. Target lesion revascularization rate was 11.7%. One patient had successful reintervention for in stent restenosis, and secondary patency rate was 93.3% at 58 months. Limb salvage rate was 84.6% during the follow-up. Two patients had myocardial infarction (11.1%) and one mortality (5.6%) occurred because of cerebrovascular event in the follow-up. Endovascular techniques can be used safely for reconstruction of the aortic bifurcation in Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease in selected patients who have high risk for open surgery. Covered endovascular reconstruction of the aortic bifurcation is the only technique that showed patency rates approaching open surgery in treatment of aortoiliac occlusive disease involving the aortic bifurcation to date. Although promising patency results were achieved with kissing-covered stents, long-term patency rates were still lower than those achieved with open surgery. Further randomized controlled studies comparing the long-term results of these techniques are needed.

A Fenestrated Balloon Expandable Stent System for the Treatment of Aortoiliac Occlusive Disease.

In aortoiliac occlusive disease, atherosclerotic plaques can occlude the distal aortic bifurcation and proximal bilateral iliac artery and thus cause ischemia in the lower extremity. This is typically treated by restoring patency with balloon expandable stents. Stents are typically deployed in a "kissing stent" configuration into the bilateral iliac arteries and into the distal aortic bifurcation lumen to restore antegrade arterial flow. However, these stents typically become re-occluded by plaques. To understand the reasons for this and look for solutions, we simulated flow dynamics in the aortic bifurcation in the presence and absence of stents using computational fluid dynamics. Results demonstrated that the kissing stent configuration was associated with high levels of vorticity and flow constriction. These prothrombotic variables were alleviated in an alternative, aortoiliac fenestrated (AIFEN), tapered, and balloon-expandable stent design. Our findings suggest that stent design can be tailored to improve flow fields for aortoiliac stenting.

Salvage Open Aortic Repair after Failed Endovascular Treatment of Aortoiliac Occlusive Disease

Salvage Open Aortic Repair after Failed Endovascular Treatment of Aortoiliac Occlusive Disease

First case report of gastric outlet obstruction due to aortofemoral bypass Dacron graft erosion of the duodenum treated with neo aortoiliac system procedure.

IntroductionGastric outlet obstruction is an uncommon complication of surgical treatment of aortoiliac occlusive disease with aortofemoral bypass. The most frequent presenting feature of duodenal erosion due to aortic synthetic graft is upper gastrointestinal bleeding, which can range from a minor “herald” bleed to exsanguinating hemorrhage.Case presentationA 64-year-old male patient with an aortofemoral Dacron bypass due to aortoiliac occlusive disease TASC II D with a chronic graft infection required emergency resection of the right limb of the Dacron graft two years ago. The patient developed abdominal pain, postprandial vomiting and progressive weight loss with an upper gastrointestinal endoscopy that showed Dacron graft material eroding into the fourth portion of the duodenum generating a gastric outlet obstruction without aortoenteric fistula and ulceration in the duodenal mucosa.Clinical discussionThe treatment goals of aortoenteric fistula are to control hemorrhage, treat infection, maintain adequate distal perfusion, graft explantation and aortic reconstructions like in this case. Traditional treatment of aortoenteric fistula is graft excision and establishing an anatomic autologous or an extra-anatomic synthetic bypass. Neo aortoiliac system procedure has shown to be the most effective and safest emerging technique today.ConclusionAortoenteric fistula is a life-threatening condition associated with high morbidity and mortality and it can also pose a diagnostic dilemma. There are many presentations of aortoenteric fistula including gastric outlet obstruction syndrome. The neo aortoiliac system procedure is the ideal curative surgical approach in stable patients.

In-Hospital Outcomes of Aortoiliac Versus Aortofemoral Bypass in Aortoiliac Occlusive Disease in Vascular Quality Initiative

This study evaluated the in-hospital outcomes of patients undergoing aortoiliac bypass vs aortofemoral bypass for the treatment of aortoiliac occlusive disease using data obtained from the Vascular Quality Initiative. Surgeries listed in the Vascular Quality Initiative that occurred during the period from January 2009 to June 2021 were queried. The primary outcome was surgical site infection (SSI). The secondary outcomes included in-hospital mortality, postoperative myocardial infarction, postoperative congestive heart failure, return to the operating room, and postoperative major amputation. Logistic regression modeling was used to adjust for potential confounders. A total of 7006 aortofemoral bypasses (90.0%) and 781 aortoiliac bypasses (10.0%) were analyzed. Most of the surgeries were performed bilaterally (aortofemoral, 95.6%; aortoiliac, 92.3%). The patients in the aortofemoral group were older (age, 60.4 ± 8.7 years vs 58.0 ± 9.6 years; P < .001) and more likely to be male (60.1% vs 36.6%; P < .001) and non-White (13.7% vs 10.9%; P = .030) compared with the aortoiliac group. The patients in the aortofemoral group also had significantly greater rates of hypertension (80.5% vs 72.7%; P < .001), coronary artery disease (22.9% vs 19.3; P = .022), and prior cardiovascular interventions, including coronary artery bypass graft/percutaneous coronary intervention (22.2% vs 17.7%; P = .003), carotid endarterectomy/carotid artery stenting (7.9% vs 5.8%; P < .001), and peripheral vascular intervention (6.5% vs 3.1%; P < .001). Patients undergoing aortofemoral interventions had significantly greater rates of both previous lower extremity intervention (12.8% vs 8.6%; P = .001) and concomitant lower extremity intervention (6.4% vs 2.8%; P < .001; Table I). Aortofemoral procedures were significantly associated with higher rates of SSIs (adjusted odds ratio, 2.4; 95% confidence interval, 1.3-4.4; P = .006) and postoperative congestive heart failure (adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.5; P = .029) compared with aortoiliac procedures. Although aortofemoral procedures were associated with greater rates of myocardial infarction compared with aortoiliac procedures (3.3% vs 1.9%; P = .040), this association did not remain significant on multivariate analysis. In-hospital death, a return to the operating room, and postoperative major amputation did not significantly differ between the two surgical techniques (Table II). Patients undergoing aortoiliac bypass had significantly lower rates of SSIs compared with those undergoing aortofemoral bypass. This likely resulted from the avoidance of groin incisions, which is known to be associated with a significantly greater risk of infections in vascular procedures. If anatomically feasible, the aortoiliac configuration in aortic reconstructions should be preferred to reduce the risk of SSI.Table IBaseline and clinical characteristics stratified by distal bypass targetCharacteristicAortofemoral (n = 7006; 90.0%)Aortoiliac (n = 781; 10.0%)P valueAge, years60.4 ± 8.758.0 ± 9.6<.001Male sex4210 (60.1)286 (36.6)<.001Non-White958 (13.7)85 (10.9).030Ethnicity (Hispanic or Latino)159 (2.3)16 (2.1).694Obesity1465 (20.9)230 (29.5)<.001Insurance.053 Medicare2124 (34.0)218 (30.3) Medicaid884 (14.2)94 (13.1) Other3241 (51.9)407 (56.6)Smoking<.001 Never132 (1.9)35 (4.5) Prior2282 (32.6)268 (34.3) Current4585 (65.5)478 (61.2)HTN5629 (80.5)563 (72.7)<.001DM1766 (25.2)208 (26.6).395CAD1605 (22.9)151 (19.3).022Prior CABG/PCI1557 (22.2)138 (17.7).003CHF508 (7.3)37 (4.7).009COPD2336 (33.4)241 (30.9).155Dialysis32 (0.5)5 (0.6).481CKD1048 (15.1)122 (15.8).606Nonambulatory149 (2.1)14 (1.8).533ASA class.172 114 (0.2)1 (0.1) 2260 (3.7)43 (5.5) 35189 (74.2)572 (73.3) 41528 (21.9)164 (21.0) 51 (0.0)0 (0.0)Prior peripheral intervention461 (6.5)24 (3.1)<.001Prior CEA/CAS554 (7.9)45 (5.8)<.001Prior aneurysm repair73 (1.0)22 (2.8)<.001Prior major amputation101 (1.4)11 (1.4).945Aspirin5140 (73.5)551 (70.6).093P2Y12 inhibitor1291 (18.5)125 (16.0).093Statin5262 (75.2)560 (71.7).033Beta-blocker3202 (45.8)339 (43.5).222RAAS inhibitor2906 (46.3)302 (42.0).029Anticoagulant542 (8.6)63 (8.8).908Urgent787 (11.2)94 (12.0).505Anesthesia (general)6889 (98.4)768 (98.3).962Right side indication.001 Asymptomatic/claudication4301 (61.6)506 (64.8) CLTI2258 (32.3)213 (27.3) Acute ischemia310 (4.4)53 (6.8) Not treated117 (1.7)9 (1.2)Left side indication<.001 Asymptomatic/claudication4292 (61.4)538 (69.1) CLTI2315 (33.1)175 (22.5) Acute ischemia285 (4.1)53 (6.8) Not treated94 (1.4)13 (1.7)Previous inflow intervention1747 (25.0)175 (22.5).120Previous LE intervention894 (12.8)67 (8.6).001Concomitant LE intervention445 (6.4)22 (2.8)<.001Bilateral surgery6697 (95.6)721 (92.3)<.001ASA, American Society of Anesthesiology; CABG, coronary artery bypass graft; CAD, coronary artery disease; CAS, coronary artery stenting; CEA, carotid endarterectomy; CHF, congestive heart failure; CKD, chronic kidney disease; CLTI, critical limb threatening ischemia; COPD, chronic pulmonary obstructive disease; DM, diabetes mellitus; HTN, hypertension; LE, lower extremity; PCI, percutaneous coronary intervention; RAAS, renin-angiotensin-aldosterone system.Data presented as mean ± standard deviation or number (%). Open table in a new tab Table IIPostoperative outcomes of aortofemoral vs aortoiliac bypass for aortoiliac occlusive diseaseOutcomeUnadjusted, No. (%)AdjustedaAortofemoral (n = 7006; 90.0%)Aortoiliac (n = 781; 10.0%)P valueaOR (95% CI)P valueSurgical site infection271 (3.9)12 (1.5).0012.4 (1.3-4.4).006In-hospital death167 (2.4)14 (1.8).2971.1 (0.6-2.1).763Postoperative MI229 (3.3)15 (1.9).0401.4 (0.8-2.3).193Postoperative CHF216 (3.1)10 (1.3).0042.2 (1.1-4.5).029Return to operating room694 (9.9)65 (8.3).1561.1 (0.8-1.5).559Postoperative major amputation68 (1.0)9 (1.2).6280.5 (0.3-1.1).087aOR, adjusted odds ratio; CHF, congestive heart failure, CI, confidence interval; MI, myocardial infarction.aReference: aortofemoral. Open table in a new tab