Long-term outcome of 121 iliofemoral endarterectomy procedures

A Decade of Progress: Assessing Three Revascularization Strategies for Iliac Occlusive Disease Through a 580-Case, 10-Year-Experience Literature Comparison

INTRODUCTION

 Peripheral arterial disease (PAD) is a critical concern, particularly in the context of an aging population and escalating risk factors such as diabetes, hypertension, and smoking. PAD leads to significant morbidity and disability, imposing considerable healthcare and economic burdens. A detailed understanding of the functional outcomes of revascularization is essential as it influences the choice of therapeutic strategies. This is crucial for the patient-doctor dialogue, enabling informed decisions based on the benefits, risks, and costs associated with each option. This study specifically examines the effectiveness of various revascularization methods for iliac occlusive disease by analyzing factors such as procedural success rates, complication frequencies, long-term patency, and patient quality of life. By evaluating these characteristics, the study aims to guide surgeons in selecting the most appropriate treatment approach in modern vascular surgery.

METHODS

A 10-year single-center retrospective analysis was conducted, examining 521 patients (580 interventions) from January 2009 to December 2018. Treatments included endovascular recanalization and stenting (endovascular treatment, EVT) (31.4%), hybrid surgical treatment (HST) (31.6%), and open surgical treatment (OST) (37.07%). The examined characteristics were primary patency, primary assisted patency, secondary patency, complications, and the degree of limb salvage.

RESULTS

The study assessed variables such as age, gender, diabetes, hypertension, dyslipidemia, smoking status, chronic kidney disease, and anesthesiological risk (American Society of Anesthesiologists (ASA) grade). Patency rates across the three methods were 92.4%, with thrombosis observed in 7.6% of cases. Assisted primary reconstructions, identified in the analysis, were few in number. Across the three revascularization strategies, a total of 41 interventions were undertaken to preserve the patency of the index reconstruction. In cases of chronic limb-threatening ischemia (CLTI), the probability of losing patency is higher and occurs earlier. OST showed the longest patency duration (471.7±71.5 days), and EVT demonstrated consistent primary patency. Complications were the highest in OST, including five perioperative mortalities. Survival analysis revealed significant differences in patency between treatment methods, with EVT and HST showing better outcomes compared to OST, particularly in patients with CLTI.

CONCLUSION

By far, this is one of the largest studies done comparing all three revascularization strategies. Endovascular, surgical, and hybrid interventions should be considered complementary elements in the vascular surgeon's toolkit. However, in the presented study, endovascular and hybrid treatment appeared to produce better outcomes compared to open surgical treatment, especially in patients with CLTI. Keeping this in mind the surgeon should be able to provide a more optimal and personalized treatment for patients with chronic lower limb ischemia.

Aortoiliac endarterectomy as a viable alternative for revascularization in a woman with isolated aortoiliac disease and an anomalous right pelvic kidney

Although the use of aortoiliac endarterectomy to treat occlusive disease has declined since the advent of endovascular procedures and operative bypass grafting techniques, clinical scenarios still exist in which it can be useful. We present the case of a patient with right lower extremity pain at rest, an anomalous right pelvic kidney, right common iliac artery occlusion, and severe left common iliac artery stenosis. We have demonstrated that aortoiliac endarterectomy should not be considered an outdated surgical technique but a viable alternative for revascularization in a specific subset of patients.

The Role of Atherectomy in Peripheral Artery Disease: Current Evidence and Future Perspectives

An ageing population and the increasing prevalence of cardiovascular risk factors have aggravated the burden of peripheral artery disease (PAD). Despite advances in the pharmacological treatment of atherosclerosis, many patients with symptomatic PAD require invasive procedures to reduce the symptoms of claudication, salvage tissue and prevent amputation and subsequent disability in those with critical limb ischaemia. After significant advances in endovascular treatment over the past two decades, these techniques are widely accepted as first-choice treatment in the majority of patients with PAD. However, in patients with severely calcified lesions, standard endovascular treatment such as plain or drug-coated balloon (DCB) angioplasty may fail due to vessel recoil or severe dissection in the acute setting, and intimal hyperplasia in the long term. With the use of percutaneous plaque modification and debulking techniques based on atherectomy, such calcified lesions can be tackled more easily after removal or fragmentation of atherosclerotic plaque. More homogeneous balloon expansion at lower pressures can be achieved after atherectomy, which reduces barotrauma while allowing better drug delivery to the vessel wall during DCB angioplasty avoids the need for stent placement. There are four principal methods of direct atherectomy available at the present time: directional atherectomy, rotational atherectomy, orbital atherectomy and hybrid atherectomy. In this article, we provide a short overview of these techniques and the current evidence from clinical trials to support their use.

A national Vascular Quality Initiative database comparison of hybrid and open repair for aortoiliac-femoral occlusive disease

OBJECTIVE

We sought to analyze the outcomes of revascularization for aortoiliac-femoral occlusive disease by comparing hybrid repair by endovascular revascularization and open common femoral endarterectomy (ER-CFE) with open aortoiliac reconstruction and CFE (OR-CFE).

METHODS

Using the national Society for Vascular Surgery Vascular Quality Initiative database from 2009 to 2015, we identified all patients receiving open or endovascular revascularization of the aortoiliac system and who additionally underwent CFE. Patients with concomitant infrainguinal procedures were excluded, as were procedures performed at centers with <50% 9-month or longer follow-up. Main outcome variables were 30-day mortality, length of stay, 1-year mortality and patency, ankle-brachial index (ABI), secondary interventions, major amputations, and ambulatory status.

RESULTS

After exclusions, the cohort comprised 879 patients in the OR-CFE group and 1472 in the ER-CFE group with follow-up of at least 9 months. Patients with ER-CFE were older (68 ± 9 years vs 63 ± 9 years; P < .001) and were more likely to have diabetes (37% vs 29%; P < .001) or heart failure (13% vs 9%; P < .01). Those receiving OR-CFE were more likely to have received a previous inflow procedure (27% vs 21%; P < .001). A greater number of arterial segments were treated or bypassed for patients undergoing OR-CFE (5.2 ± 1.6 vs 2.9 ± 1.0; P < .01). ER-CFE was associated with lower 30-day mortality (1.8% vs 3.4%; P = .01), shorter length of stay (median 3 vs 7 days; P < .001), and higher 1-year mortality (8.6% vs 6.3%; P = .04). The two cohorts had equivalent major amputation rate (2.8% vs 2.9%; P = .84). Patients with OR-CFE had greater ABI improvement at long-term follow-up (0.39 ± 0.37 vs 0.26 ± 0.23; P < .001) and were more likely to achieve improved ambulatory status (82% vs 65%; P < .001).

CONCLUSIONS

For patients with aortoiliac-femoral occlusive disease, endovascular repair with concomitant CFE appeared to have improved short-term outcomes and equivalent freedom from major amputation compared with open surgical repair with CFE. Conversely, open repair with CFE was associated with better long-term improvement in ABI and ambulatory status. Open repair should therefore be considered for patients with aortoiliac-femoral occlusive disease and reasonable surgical risk.

Does Conversion of Intended Remote Iliac Artery Endarterectomy Alter the Early and Long-Term Outcome?

The purpose of this study was to compare the perioperative and long-term results of initial successful remote iliac artery endarterectomies (RIAEs) with converted procedures.

From April 1994 to September 2003, 63 remote endarterectomies of the external and/or common iliac artery were planned in 62 patients (41 males, 42 procedures). The median age was 65 years (range 39–83 years), and the indication for operation was severe claudication in 37 (59%), rest pain in 16 (25%), and gangrene in 10 (16%) procedures.

Initial technical success was achieved in 56 (89%) procedures (group 1); seven conversions (group 2) were necessary. In group 1, the 5-year primary patency rate improved from 64 ± 15% to a primary assisted patency of 88 ± 9.3% after percutaneous transluminal angioplasty in 11 patients, with 7 requiring stent placement. The 5-year secondary patency rate was 94 ± 7.4%. The primary and secondary patency rates in group 2 were 86 ± 19% and 100%, respectively.

RIAE can be offered to patients with long occlusions of the iliac arteries as a first treatment option. The inherent risk of a possible conversion of an intended RIAE to a more invasive surgical procedure has no significant adverse clinical effect on the early and 5-year clinical outcomes.

Single-incision external iliac artery endarterectomy and patch angioplasty

An isolated external iliac artery chronic total occlusion is currently treated either with subintimal percutaneous transluminal angioplasty and stent or with a bypass. This article describes a new application of an old technique, endarterectomy and patch angioplasty, performed on the external iliac artery through a single flank incision. This novel approach can provide lasting patency with a low risk of complications. We present four cases and a review of the literature on the other available treatment options. This minimally invasive technique may provide a viable alternative that can be used alone or in combination with other open or endovascular techniques and can be applied in cases of groin sepsis.

Use of extraperitoneal iliac artery endarterectomy in the endovascular era

Although iliac artery (IA) endarterectomy has largely been replaced by bypass and endovascular options, open endarterectomy continues to play an important role in selected patterns of occlusive disease. The objective of this report is to present a contemporary clinical series of patients having undergone IA endarterectomy. Specifically, we define patterns of disease amenable to open endarterectomy and provide an updated technical note of this procedure. A retrospective study on 23 patients with IA occlusions unsuitable for radiologic intervention (TransAtlantic Inter-Societal Consensus [TASC] C and D lesions) underwent extraperitoneal IA endarterectomy. Twenty-five primary IA endarterectomies were performed. Of these, five required more extensive endarterectomy, three of the distal aorta and two of the contralateral IA. Sixteen of the 25 endarterectomies required common femoral artery endarterectomy and 6 required iliofemoral bypass. The average follow-up was 26 months. Procedure-related mortality occurred in one patient (4.3%). Within 4 months, one patient underwent an aortofemoral bypass and two patients required major amputation. Primary patency rates were 96% at 3 months and 88% at 1, 2, and 3 years. This series shows that in selected patterns of aortoiliac occlusive disease, endarterectomy remains an important alternative to consider.

Long-term results of combined common femoral endarterectomy and iliac stenting/stent grafting for occlusive disease

BACKGROUND

Common femoral artery (CFA) endarterectomy with iliac stenting or stent grafting can be an alternative to traditional open surgery in patients with aortoiliac occlusive disease. We report the long-term outcomes of this approach.

METHODS

Patients undergoing CFA endarterectomy with simultaneous iliac stenting/stent grafting between 1997 and 2006 were retrospectively reviewed. Technical success, clinical and hemodynamic outcomes, and 5-year patency using life-table methodology were determined. Factors associated with reintervention and mortality were determined by logistic regression analysis.

RESULTS

A total of 171 patients (mean age, 67 +/- 10 years; 38% female; 35% diabetic) underwent 193 CFA endarterectomies and iliac stent/stent grafting. Indications were rest pain (32%), tissue loss (22%), and claudication (46%). External iliac artery (EIA) lesions were present in 39%, and combined common iliac artery (CIA) and EIA lesions were seen in 61% of patients. Complete CIA/EIA occlusions were present in 41% of patients. Stent grafts were used in 41% of patients. Technical success occurred in 98% of patients. Clinical improvement was seen in 92% of patients. Mean ankle-brachial index increased from 0.38 +/- 0.32 to 0.72 +/- 0.24. Median length of stay was 2 days (range, 1-51 days). Thirty-day mortality was 2.3% and 5-year survival was 60%. Five-year primary, primary-assisted, and secondary patencies were 60%, 97%, and 98% respectively. Endovascular reintervention was required in 14% of patients; inflow surgical procedures were required in 10%. By logistic regression analysis, use of stent grafts compared with bare stents was associated with significantly higher primary patency (87% +/- 5% vs 53% +/- 7%; P < .01).

CONCLUSION

Combined CFA endarterectomy with iliac intervention yield acceptable long-term results. The use of stent grafts compared with bare stents is associated with improved primary patency.

Remote iliac artery endarterectomy: seven-year results of a less invasive technique for iliac artery occlusive disease

OBJECTIVE

Remote endarterectomy of external and common iliac artery occlusions through a single, groin incision under fluoroscopic guidance is a relative unknown surgical procedure. This prospective single center cohort study describes this less invasive endovascular technique with the ring strip cutter and its early complications. The results at midterm follow-up are presented.

PATIENTS AND METHODS

From April 1994 to July 2001, 49 remote-endarterectomies of the external or common iliac artery were performed in a retrograde manner from a single, groin incision in 48 patients (30 men, 31 procedures). The median age was 66 years (39 to 82 years). Indications for operation were as follows: severe claudication in 28 (57%), rest pain in 13 (27%), and gangrene in 8 (16%) procedures. Follow-up included clinical evaluation, ankle-brachial index, and duplex scanning at 6 weeks, 3 months, and yearly thereafter.

RESULTS

Intraoperative technical success was achieved in 43 (88%) procedures. A retroperitoneal incision was necessary in three patients for an additional arteriotomy in the iliac artery and in three others for a bypass procedure. The mean follow-up was 20 months (2 to 77 months). Three-year cumulative primary patency rate by means of life table analysis was 60.2% +/- 12.0 (SE). During follow-up, percutaneous transluminal balloon angioplasty with and without stenting was performed in six and two patients, respectively, resulting in a 3-year primary-assisted patency rate of 85.7% +/- 9.56. Three-year secondary patency was 94.2% +/- 5.50.

CONCLUSIONS

Remote endarterectomy in external and common iliac arterial occlusive disease is a feasible endovascular procedure with a low complication rate. The midterm primary-assisted patency rate is good.

Digital fluoroscopy as a valuable adjunct to open vascular operations

The increasing availability of and vascular surgeons' familiarity with digital cine-fluoroscopy in the operating room has been facilitated by the advent and growing popularity of endovascular aortoiliac aneurysm repair and other endovascular techniques that are being incorporated into vascular surgical practice. Digital cine-fluoroscopy can also be used as a valuable adjunct to standard open vascular procedures in several ways including: performance of completion angiography, fluoroscopically-assisted thromboembolectomy, intraoperative planning angiography, fluoroscopically-guided pressure gradient measurements, achieving vascular control of proximal arteries, intraoperative thrombolysis of compromised outflow tracts, and angioplasty and stenting of lesions detected intraoperatively. These techniques can improve the outcome of standard vascular procedures by permitting the identification of inflow, outflow, conduit, and anastomotic defects intraoperatively and guiding their repair. Additionally, in many cases they can reduce the amount of exposure required, reduce intraoperative blood loss, and minimize trauma to vessels during thrombectomy. Fluoroscopic guidance can facilitate and improve these and other aspects of standard open vascular procedures. Conversely, the ability to perform open interventions can facilitate the performance of many endovascular interventions. It is becoming increasingly important to be facile with both open and E fluoroscopically guided techniques in order to fully treat the spectrum of vascular disease in an optimum fashion.