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The Management Of Severe Aorto-Iliac Occlusive Disease: Endovascular Therapy Rivals Open Reconstruction

Vikram S Kashyap, Mircea L. Pavkov, James F. Bena, Timur P. Sarac, Patrick J. O'Hara, Sean P. Lyden, Sunita Srivastava, Daniel G. Clair.
The Cleveland Clinic Foundation, Cleveland, OH.

OBJECTIVES: The purpose of this study was to compare the outcomes and durability of recanalization (R), percutaneous transluminal angioplasty (PTA) and stenting (S) to aortobifemoral bypass (ABF) for patients with severe aorto-iliac occlusive disease (AIOD).

METHODS: Between 1998 and 2004, 75 patients (150 limbs) underwent ABF while 73 patients (107 limbs) underwent R/PTAS. All patients had severe symptomatic AIOD (claudication 53%, rest pain 30%, tissue loss 12%, acute limb ischemia 5%). Patients with aneurysms and extra-anatomic procedures, as well as, endovascular treatment of iliac stenoses were excluded from analyses. Original angiographic imaging, medical records and non-invasive testing were reviewed. Kaplan-Meier estimates for patency and survival were calculated. Mortality was verified via the Social Security database.

RESULTS: Patients undergoing ABF had a mean age 59 yrs and 64% were male. Patients undergoing R/PTAS were older (66 yrs, P < 0.001), but had lower rates of hyperlipidemia (P = 0.039) and smoking (P < 0.001). All other clinical variables including cardiac status, diabetes, symptoms at presentation, TASC classification and presence of poor outflow were similar between the two groups. ABF patients had treatment of femoral disease (60% endarterectomy, profundaplasty), and technical success was universal, but there were 6 perioperative deaths (8%). Patients underwent R/PTAS with local anesthesia/sedation (78%) with a 96% technical success rate and 1 perioperative death (1.4%). Seventeen patients (23%) underwent femoral endarterectomy, or bypass (n=5) for concomitant infrainguinal disease at the time of R/PTAS. Mean ABI for all patients increased from 0.49 to 0.87. Primary patency for ABF was significantly higher than for R/PTAS (3 yr: 93% vs. 75%, P=0.003). Secondary patency rates were similar (97% vs. 95%, P=0.3) and long-term survival trended lower in patients undergoing ABF (3 yr: 73% vs. 83%, P=0.19).

CONCLUSIONS: Patients with severe AIOD can be treated with ABF or R/PTAS with durable results. Compared to ABF, R/PTAS is associated with decreased perioperative mortality and primary patency, but similar secondary patency and long-term survival rates. Repair of the concomitant femoral occlusive disease is crucial regardless of open or endovascular treatment.