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Unilateral Iliac Artery Occlusive Disease: Long Term Results Of A Randomized Multicenter Trial Examining Direct Revascularization Versus Crossover Bypass

Jean-Baptiste Ricco, Sr.¹, Hervé Probst, Jr.², For the AURC: Association Universitaire de Recherche en Chirurgie.
¹University of Poitiers, Poitiers, France; ²University of Lausanne, Lausanne, Switzerland.

OBJECTIVES: To compare the late patency of direct aorto- or iliofemoral bypasses to that of crossover bypasses in good risk patients with unilateral iliac atheromatous occlusion and disabling claudication.

METHODS: Between May 1986 and March 1991, 143 patients were enrolled in this multicenter study (74 crossover and 69 direct revascularizations). The number of patients to be included was calculated to show a possible difference of 20% in patency in favor of direct bypasses at 3-year with a type I risk of 5% and a type II risk of 10%. Cardiovascular risk factors, preoperative symptoms, and atheromatous lesions were comparable in both groups. Iliac lesions were classified as TASC C in 87 patients (61%) and TASC D in 56 patients (39%). Superficial femoral artery (SFA) on the side of femoral revascularization was occluded in 30 patients with crossover bypass (41%) and in 25 patients with direct bypass (36%). Patients were followed every year by duplex scanning with systolic pressure measurements. Routine digital angiography was obtained when hemodynamic anomalies developed. Mean follow-up was 10 years. Primary endpoint was patency calculated by the Kaplan-Meier method, secondary endpoints were postoperative mortality and morbidity.

RESULTS: One patient with a direct bypass died postoperatively. Primary patency at 10 years was 83 ± 7% for the direct bypasses and 56 ± 6% for the crossover bypasses (p=0.01). The numbers of patients at risk at five and ten years were respectively 116 (81%) and 80 (56%). Secondary patency at 10 years was 95±3 % for the direct procedures and 83±5% for the crossover procedures (p=0.03). Patency of the crossover bypasses was significantly inferior when the receiving SFA was occluded (72±6% vs. 52±10% at 5 years). PTFE and polyester crossover grafts had similar patency at 10 years. Groin complications were more frequent in patients with crossover bypass (n=10, 13.5%) than in patients with direct bypass (n=3, 4.5%) (p=0.16). Survival was 60 ± 7% at 10 years.

CONCLUSIONS: This long-term study shows that crossover bypasses should be reserved for patients at risk with a unilateral iliac occlusion that cannot be recanalized via a percutaneous approach.