Is the iliac artery a suitable inflow conduit for iliofemoral occlusive disease: An analysis of 514 aortoiliac reconstructions

Advances in the Management of Iliac Artery Occlusive Disease: A Short Review

There have been considerable advances in the management of patients with aortoiliac occlusive disease. While endovascular procedure is the treatment of choice for Trans-Atlantic Inter-Society Consensus (TASC) type A and is more often used in TASC type B iliac lesions, recent studies report encouraging results in patients with intermittent claudication suffering from TASC type C and D iliac disease. Modern surgical techniques have been proposed for the treatment of high-risk subjects with critical limb ischemia due to advanced aortoiliac disease. Combined or hybrid interventions involving endovascular and open procedures performed either successively or intraoperatively are becoming more popular as vascular surgeons acquire endovascular skills. However, the long-term results of these therapies especially in the presence of multilevel occlusive lesions still remain uncertain.

Retroperitoneal "Mini" Approach for Aortoiliac Reconstructive Surgery

The large vertical midline or transverse transperitoneal approaches used in the conven tional aortoiliac reconstruction are accompanied with a relatively high postoperative morbidity and mortality rate (2% to 5%), even in patients who are good risks under going aortic surgery. The purpose of this study was develop a new technique for aorto bifemoral bypass operation to minimize the operative stress on these patients.

Methods: The recommended left paramedian or transmuscular retroperitoneal approach, using 5-6 cm skin incision and a special retractor with three-dimensional vision and with modified surgical instruments directly under eye control, offers the possibility of decreasing the operative stress significantly and of sufficiently controlling the serious bleeding that might occur. If necessary, this exposure can be immediately converted to a conventional approach by simple enlargement of the incision.

Results: In the authors' first cases the functional results were very good, and conse quently, hospitalization time and the convalescence period were short.

Conclusion: This minimal access approach appears to diminish the catabolic response, and it is hoped that it will be associated with accelerated recovery and virtual abolition of large wound-related complications. It could become the procedure of choice for selected patients with obstructive or aneurysmal aortoiliac disease.

Iliac and Femoropopliteal Lesions: Evaluation of Balloon Angioplasty and Classical Surgery

Purpose:

The purpose of this study was to compare the characteristics of patients treated for atherosclerotic disease of the lower extremities with balloon angioplasty (BA) or classical surgery (CS) and to assess the outcome of both techniques.

Methods:

The records of 1364 patients who were treated with BA or CS for chronic lower limb ischemia between 1986 and 1993 were analyzed. Demographic features of patients, immediate and long-term survival, patency, and amputation rates were compared in both groups according to the level of the revascularization (iliac or femoropopliteal).

Results:

Patients undergoing BA were slightly younger (62.3 years versus 65.9 years for CS group; p = NS) and demonstrated symptoms consistent with less severe atherosclerotic disease (81% claudication in the BA group versus 48% in the CS patients; p < 0.001). At 30 days post-treatment in the BA and CS groups, respectively, there were 0.7% and 4% deaths (p < 0.01); 13% and 6% primary failures (p = 0.013); 13% and 6% secondary failures (p = 0.01); 0.3% and 12% general complications (p = 0.001); and 3% and 8% nonvascular complications (p = 0.007). At the iliac level, in the angioplasty (n = 134 limbs) and surgery (n = 721 limbs) groups, respectively, the mean age was 57.6 and 63.7 years (p < 0.01), and claudication was present in 91% and 72. Perioperative mortality was 0% and 1.9. The 4-year survival rates were 95% and 88%; patency was 70% and 79%; and the amputation rates were 0% and 5. At the femoropopliteal level, in the angioplasty (n = 138 limbs) and surgery (n = 656 limbs) groups, respectively, the mean age was 67.8 and 66.8 years (NS), and claudication was present in 69% and 28. Perioperative mortality was 0.9% and 5.5. The 4-year survival rates were 95% and 78%; and patency was 44% and 65. At 2 years, the amputation rates were 6% and 12.

Conclusions:

Patients treated by BA were younger, especially in the iliac group, and had less symptomatic lesions than patients treated with surgery. Surgery achieved a better long-term patency at the cost of a higher immediate complication rate and mortality. Whenever technically feasible, BA may be the better choice for initial therapy in appropriate patients suffering from chronic lower limb ischemia.

Combined Direct Repair and Inline Inflow Stenting in the Management of Aortoiliac Disease Extending Into the Common Femoral Artery

Purpose: Describe a hybrid approach to simplify management of complex aortoiliac occlusive disease (AIOD) extending into the common femoral artery (CFA). Methods: Retrospective review of 56 patients who underwent hybrid management of AIOD extending into CFA between January 2003 and February 2007. Two distinct hybrid approaches were compared: Inline (iliac stenting continuous with an open CFA reconstruction, 38 limbs in 37 patients) and tandem (noncontiguous stenting of an upstream iliac segment, 20 limbs in 19 patients). The median follow-up duration was 15 ± 12 months in the inline group and 24 ± 12 months in the tandem group. Results: Technical success was achieved in all but 1 procedure. Clinical and hemodynamic responses to the interventions and limb loss rates were comparable in both groups. Survival table analysis showed no significant difference between inline and tandem reconstructions. Conclusions: Inline stenting represents a lesser invasive revascularization choice in complex AIOD with contiguous involvement of the CFA.

Contemporary Outcomes of Iliofemoral Bypass Grafting for Unilateral Aortoiliac Occlusive Disease: A 10-Year Experience

Current treatment of complex aortoiliac occlusive disease (AIOD) includes the aortobifemoral bypass or the femoral-femoral bypass. However, because of bilateral groin exposure and associated risks, there is a significant morbidity associated with these procedures. In appropriate patients with unilateral AIOD, the iliofemoral bypass graft (IFBPG) via a lower abdominal retro-peritoneal incision can be an acceptable alternative. The purpose of this study is to review the safety and efficacy as well as long-term outcomes of IFBPG in patients with unilateral AIOD. From July 1997 through June 2006, 40 patients (64.3 ± 11.2-years-old, range 41–89-years-old, 57.5% critical limb ischemia, 70% male, 95% smokers) with unilateral AIOD were treated with IFBPG. Perioperative complications and symptom resolution were measured and Kaplan-Meier life table analysis was used to analyze outcomes of primary and secondary patency, survival, limb salvage, contralateral intervention, and maintenance of ambulation and independent living status. The perioperative complication rate was 12.5 per cent (n = 5) including one patient who developed atrial-fibrillation and one who developed acute renal failure. Both patients experienced resolution of these symptoms before discharge. Other complications included one limb thrombosis and two wound infections. There were no perioperative deaths. Secondary patency was 97.5 per cent and 93.3 per cent at 1 and 5 years. Limb salvage in patients with critical limb ischemia (CLI) was 85.1 per cent and 79.1 per cent at 1 and 5 years. Limb amputation occurred due to infection (n = 2), or failed IFBPG (n = 2). Thirty-one patients (77.5%) experienced symptom resolution including 15 (88.2%) of the patients treated for claudication. Two patients (5%) required contralateral iliac intervention. Patient survival was 97.5 per cent and 64.5 per cent at 1 and 5 years. Greater than 90 per cent of patients maintained their functional independence at 5 years. IFBPG achieved excellent technical and functional outcomes, particularly in patients treated for vasculogenic claudication. This procedure is relatively safe and efficacious in a population of patients with complex unilateral AIOD and can be an acceptable alternative to the aortobifemoral bypass or fem-fem procedure.

A personal experience with direct reconstruction and extra-anatomic bypass for aortoiliofemoral occlusive disease

OBJECTIVE

This study was conducted to investigate factors influencing the outcome of all open operations for aortoiliofemoral (AIF) revascularization performed by a single surgeon at a tertiary referral center.

METHODS

The series included 355 direct reconstructions and 181 extra-anatomic bypass (EAB) grafts in 339 men (63%) and 197 women, with median ages of 61 and 62 years, respectively. These procedures were done for claudication alone in 267 patients (50%), for advanced ischemia in 258 (48%), and to facilitate other interventions in 11 (2.0%). Simultaneous infrainguinal bypass was necessary in 36 patients (6.7%). Survival and patency analyses were performed using logistic regression, Kaplan-Meier estimations, and proportional hazards models.

RESULTS

Patients receiving EAB were older (P < .001) and were more likely to have advanced preoperative limb ischemia (P < .001), superficial femoral artery occlusions (P < .001), a history of previous lower extremity inflow operations (P < .001), elevated serum creatinine (P = .017), and clinically severe chronic obstructive pulmonary disease (P = .016). On multivariable analysis, EAB resulted in a higher incidence of postoperative death (8.8% vs 2.3%, P = .005) or graft thrombosis (8.8% vs 2.8%, P = .006) than direct reconstruction. Women were more likely to sustain graft thrombosis (P = .006) or require major amputation (P = .050), or both, during the early postoperative period. Overall late survival rates were 87% +/- 3% at 1 year, 64% +/- 5% at 5 years, 39% +/- 5% at 10 years, and 20% +/- 4% at 15 years. Late survival rates were significantly lower (P = .026) after EAB and also were unfavorably associated with advanced preoperative ischemia (P = .046) as well as with several medical comorbidities (P < .001). Primary limb-based patency rates were 95% +/- 2% at 1 year, 85% +/- 3% at 5 years, 77% +/- 5% at 10 years, and 69% +/- 7% at 15 years. Late occlusions occurred more frequently in patients who had undergone previous inflow procedures (P = .028) and were especially common after EAB (P < .001). Patients >65 years had higher early and late mortality rates than younger patients (P < .001), but younger patients had lower long-term patency rates (P < .001).

CONCLUSIONS

The worse operative mortality and late survival rates for EAB in this series largely were preordained by the frequent selection of EAB for patients who represented poor medical risks for direct AIF reconstruction. However, the durability of aortofemoral, aortoiliac, or iliofemoral bypass compared with either femorofemoral or axillofemoral bypass makes direct reconstruction clearly superior for average or low-risk patients. Direct reconstruction should be used preferentially in such cases, especially in women and for younger patients of either gender.

Videoendoscopically assisted combined retroperitoneal and pelvic extraperitoneal approach for aortoiliac occlusive disease

BACKGROUND

Laparoendoscopic surgery has emerged as a new method for the management of iliac and aortoiliac occlusive disease. This article describes a combined retroperitoneal and pelvic extraperitoneal approach to aorta and iliac arteries.

METHODS

A review was performed for 15 patients who underwent videoendoscopically assisted vascular bypass procedures between January 1999 and June 2003. A minimal access approach was used for access to the proximal anastomotic site (proximal common iliac or distal aorta) and creation of a tunnel for the prosthetic graft placement up to the distal anastomotic site. Altogether, 11 iliofemoral bypasses, 2 iliobifemoral bypasses and 2 aortobifemoral bypasses were performed. Patients with diffuse stenosis/long-segment occlusion and multiple lesions for whom percutaneous transluminal angioplasty with stenting proved to be unsuitable were included. The outcome parameters measured were intraoperative time, intraoperative blood loss, skin incision length, length of hospital stay, postoperative pain and analgesia requirement, and patency of graft.

RESULTS

Videoendoscopy was used to complete 14 procedures. The mean operating time was 258 +/- 49 min (range, 180-300 min) and the mean blood loss was 124 +/- 28.23 ml (range, 80-150 ml). The mean hospital stay was 6.7 +/- 4.46 days (range, 4-9 days). After a mean follow-up period of 14.4 +/- 3.55 months (range, 6-20 months), all grafts were patent.

CONCLUSION

Videoendoscopically assisted vascular surgery for iliac and aortoiliac occlusive disease by a combined retroperitoneal and pelvic extraperitoneal approach is feasible and appears to confer many advantages of minimal access surgery. However, prospective randomized trials are needed to define clearly any advantages of this approach over conventional surgery.

Early results of external iliac artery stenting combined with common femoral artery endarterectomy

PURPOSE

The endovascular approach to external iliac artery (EIA) disease extending into the common femoral artery (CFA) has been avoided because of problems with stent placement across the inguinal ligament. Surgical treatment for this disease distribution includes extensive endarterectomy or bypass procedures or both. We report our initial experience with a combined open and endovascular approach to these patients.

METHODS

We performed a retrospective analysis of all patients who underwent intraoperative EIA stenting after CFA endarterectomy/patch angioplasty between 1997 and 2000. Stents were positioned to end at the proximal endarterectomy endpoint, without crossing the inguinal ligament. Technical success, hemodynamic success, and clinical success were determined according to Society of Vascular Surgery/International Society of Cardiovascular Surgery criteria. Life-table analysis was performed for patency.

RESULTS

Thirty-four patients (mean age, 68 years; 23 male, 11 female) had combined endovascular and open treatment of iliofemoral occlusive disease. Indications were claudication in 41% and critical limb ischemia in 59%. Femoral reconstruction included endarterectomy with patch angioplasty in all patients. EIA stent deployment incorporated the stenotic iliac segment and the proximal endpoint of the endarterectomy in all patients. Four patients (12%) also needed common iliac angioplasty at the same time for proximal iliac disease, and 14 patients (41%) also needed distal revascularization for associated femoropopliteal or tibial disease. Technical success and hemodynamic success were achieved in 100% of patients. Clinical success was achieved in 97% of patients. The mean postoperative increase in ankle-brachial index in patients with inflow procedures only was 0.36 (range, 0.1 to 0.85). The overall complication rate was 15%. With a mean follow-up period of 13 months (range, 0.5 to 28 months), 1-year primary patency and primary-assisted patency rates were 84% and 97%, respectively. No perioperative mortality was seen.

CONCLUSION

EIA stenting as an adjunct to CFA endarterectomy/patch angioplasty allows for more localized surgery than conventional bypass. This approach also allows a better interface between the stent and endarterectomy than staged preoperative stenting. Technical success and early patency rates are excellent.

Long-term results of stenting for chronic iliac artery occlusion

PURPOSE

To evaluate the long-term results of stent placement for chronic occlusions of the iliac arteries.

METHODS

Between October 1992 and December 1997, 73 patients (40 men; median age 64 years, range 42-89) with 76 occluded iliac arteries (33 common, 34 external, and 9 both vessels) were treated with percutaneous recanalization and stenting using a variety of self-expanding and balloon-expandable devices. Median occlusion length was 7 cm (range 1-14). Follow-up consisted of clinical assessment, ankle-brachial index measurement, and arteriography or duplex ultrasound when indicated.

RESULTS

Anatomical success was achieved in 74 (97%) limbs. Seven (10%) patients experienced major complications: 2 distal embolizations, 2 arterial ruptures, 1 myocardial infarction, 1 groin hematoma requiring surgery, and 1 contrast-induced nephropathy. There was no 30-day mortality. Over a median follow-up of 27 months (range 1-75), there was 1 early occlusion (< or = 30 days) and 16 late recurrent lesions (11 occlusions and 5 stenoses) at a median 6.2 months (range 1.4-30). The recurrent lesions were treated with endovascular techniques in 8 limbs and surgery in 7 limbs (5 after failed endovascular procedures); 1 patient died before retreatment, and 1 patient refrained from further intervention. Primary and secondary patencies were 79% and 87% at 1 year and 69% and 81% at 3 years, respectively.

CONCLUSIONS

Stenting of chronic iliac occlusions is a safe and durable alternative to surgical treatment.

Combined use of iliac artery angioplasty and infrainguinal revascularization for treatment of multilevel atherosclerotic disease

The purpose of this report is to review our recent experience with the combined use of iliac artery angioplasty and infrainguinal surgical revascularization for the treatment of multilevel atherosclerotic disease. A retrospective review of all patients with multilevel atherosclerotic disease who were treated with both iliac artery angioplasty and infrainguinal bypass surgery during a 4-year period was performed. The medical records and preoperative arteriograms of all patients were reviewed for demographic information, radiologic findings, and postoperative follow-up data. Ninety-three limbs in 87 patients were studied. There were 57 male and 30 female patients with an average age of 67.2 years (range: 38-90). We concluded that the combined use of iliac artery angioplasty and infrainguinal surgical revascularization is an effective and durable means of treating multilevel atherosclerotic disease.

Current controversies in the management of aortoiliac occlusive disease

The numerous options currently available for treatment of aortoiliac occlusive disease have led to considerable controversy in regard to the optimal method of revascularization in such patients. Differences of opinion exist not only with respect to certain technical aspects of direct anatomic aortic reconstruction, which has traditionally been regarded as the "gold standard" treatment, but even more importantly as to whether alternative methods including a variety of catheter-based endoluminal therapies and extraanatomic grafts may offer nearly equivalent results with less risk and possible cost advantages. Although little truly definitive data is available, a review of published information can help clarify many of these management dilemmas. In the final analysis, the various methods may not be as competitive with one another as first seems apparent. Each has its own specific advantages and disadvantages and when used, in appropriate circumstances can provide excellent results. Indeed, it is this broad spectrum of options that can be matched to each patient's own unique anatomic and risk characteristics that make treatment of aortoiliac disease one of the most successful areas of contemporary vascular surgery practice.

The crossover femoropopliteal bypass: a useful option for unilaterial iliofemoral occlusive disease

OBJECTIVE

To study the outcome of treating critical limb ischaemia due to concurrent, unilateral iliac and femoral arterial occlusive disease by the placement of a crossover femoropopliteal bypass graft.

DESIGN

Retrospective study of 10 patients unfit for aortic reconstruction whose disease was not amenable to endovascular therapy who were treated with this graft.

MATERIALS

Seven grafts originated from the common femoral artery, two from aortobifemoral graft limbs and one from the common iliac artery. There was not direct revascularisation of the profunda femoris artery. The distal anastomosis was to the above-knee popliteal artery in nine cases and to the below-knee popliteal artery in one.

OUTCOME MEASURES

Follow-up after discharge from hospital consisted of regular ankle-brachial index measurement and Duplex ultrasound scan assessment to record graft patency and limb salvage.

RESULTS

The median duration of secondary patency was 52.5 months (range 14-84). During follow-up, there were four occlusive events. One graft had its patency restored, but in the other three patients, graft occlusion was associated with limb loss (at 18, 51 and 83 months respectively). In one of this latter group, surveillance had identified a failing graft and a jump graft prolonged patency for a further 34 months.

CONCLUSION

This experience demonstrates that the crossover femoropopliteal bypass achieves satisfactory limb salvage in patients with extensive iliofemoral occlusive disease who are not suitable for major aortic reconstruction.

Conventional versus endovascular surgical procedures: a no choice option

The on-going debates on the competitiveness of endovascular and conventional surgery in the treatment of peripheral occlusive vascular diseases are justified by the fact that endovascular procedures are associated with a lower mortality and morbidity, require a shorter hospital stay, and are less costly than conventional surgery. However, scientific and economic comparisons between the two techniques are difficult because they cannot strictly be applied to the same patients. Patients who may benefit from endovascular surgery are generally at an earlier stage of the disease, they have claudication and short stenoses or occlusion. On the other hand, patients who present with severe claudication or critical ischaemia, in most cases, have long occlusions, multiple segmental disease and often require conventional surgery.

A randomised, clinical study of the effect of low-dose dopamine on central and renal haemodynamics in infrarenal aortic surgery

OBJECTIVE

To determine whether dopamine prevents deterioration of central haemodynamics and renal function in aortoiliac surgery.

DESIGN

Prospective, randomised and placebo-controlled.

SETTING

University hospital.

MATERIALS

Thirty patients for elective vascular surgery with implantation of an aortobifemoral or an aortobiiliac graft due to aortoiliac arteriosclerosis had infusion of dopamine 3 micrograms/kg/min or placebo during the operation and 24 h postoperatively. Thoracic epidural analgesia and general anaesthesia were used.

CHIEF OUTCOME MEASURES

Central haemodynamic measurements were registered. The effective renal plasma flow (ERPF), the glomerular filtration rate (GFR), angiotensin II, aldosterone, arginine vasopressin (AVP), atrial natriuretic peptide (ANP), endothelin and excretion of water and electrolytes were measured preoperatively, 1 h postoperatively and 24 h postoperatively.

MAIN RESULTS

During the operation the dopamine group had higher cardiac index and heart rate together with lower pulmonary artery wedge blood pressure. ERPF and GFR did not differ between the groups. In the dopamine group ERPF was increased in all patients at the first postoperative clearance. The fractional excretion of sodium, the per- and postoperative diuresis and AVP were increased in the dopamine group as compared to the placebo group. Postoperatively, ANP in the placebo group was raised as compared to the preoperative level.

CONCLUSIONS

Peroperatively, dopamine counteracted depression of left ventricular function. The increased ERPF at the first postoperative clearance in the dopamine group indicates either improved peroperative haemodynamics or a synergistic effect between dopamine and epidural sympathetic blockade. Dopamine also improved diuresis and natriuresis.

Iliac and femoropopliteal lesions: evaluation of balloon angioplasty and classical surgery

PURPOSE

The purpose of this study was to compare the characteristics of patients treated for atherosclerotic disease of the lower extremities with balloon angioplasty (BA) or classical surgery (CS) and to assess the outcome of both techniques.

METHODS

The records of 1364 patients who were treated with BA or CS for chronic lower limb ischemia between 1986 and 1993 were analyzed. Demographic features of patients, immediate and long-term survival, patency, and amputation rates were compared in both groups according to the level of the revascularization (iliac or femoropopliteal).

RESULTS

Patients undergoing BA were slightly younger (62.3 years versus 65.9 years for CS group; p = NS) and demonstrated symptoms consistent with less severe atherosclerotic disease (81% claudication in the BA group versus 48% in the CS patients; p < 0.001). At 30 days post-treatment in the BA and CS groups, respectively, there were 0.7% and 4% deaths (p < 0.01); 13% and 6% primary failures (p = 0.013); 13% and 6% secondary failures (p = 0.01); 0.3% and 12% general complications (p = 0.001); and 3% and 8%, nonvascular complications (p = 0.007). At the iliac level, in the angioplasty (n = 134 limbs) and surgery (n = 721 limbs) groups, respectively, the mean age was 57.6 and 63.7 years (p < 0.01), and claudication was present in 91% and 72%. Perioperative mortality was 0% and 1.9%. The 4-year survival rates were 95% and 88%; patency was 70% and 79%; and the amputation rates were 0% and 5%. At the femoropopliteal level, in the angioplasty (n = 138 limbs) and surgery (n = 656 limbs) groups, respectively, the mean age was 67.8 and 66.8 years (NS), and claudication was present in 69% and 28%. Perioperative mortality was 0.9% and 5.5%. The 4-year survival rates were 95% and 78%; and patency was 44% and 65%. At 2 years, the amputation rates were 6% and 12%.

CONCLUSIONS

Patients treated by BA were younger, especially in the iliac group, and had less symptomatic lesions than patients treated with surgery. Surgery achieved a better long-term patency at the cost of a higher immediate complication rate and mortality. Whenever technically feasible, BA may be the better choice for initial therapy in appropriate patients suffering from chronic lower limb ischemia.

Femorofemoral versus aortobifemoral bypass: outcome and hemodynamic results

PURPOSE

Femorofemoral bypass (FFB) is used in selected patients when aortobifemoral bypass (AFB) is believed to be inappropriate because of high operative risk or predominantly unilateral iliac artery occlusive disease. We examined concurrent patients who underwent either FFB or AFB to better understand the appropriate use of FFB.

METHODS

The characteristics and outcomes of patients who underwent FFB and AFB during 1986 to 1991 at our institution were retrospectively reviewed. Primary measures of outcome included patient survival, graft patency, limb salvage, and hemodynamic performance of FFB and AFB. Further analysis was performed after substratification for low versus high risk and claudication versus limb threat as the indication for surgery.

RESULTS

FFB was performed in older patients with more medical comorbidities when compared with AFB. Long-term graft patency was inferior after FFB compared with AFB (60% vs 85% at 3 years, p < 0.01). However, both FFB and AFB achieved limb salvage in more than 85% of patients at 3 years. When patients at low risk undergoing nonemergency AFB were compared with patients at low risk who underwent FFB and who had no contraindication to AFB, FFB proved inferior to AFB as measured by graft patency (primary patency 61% vs 87% at 3 years, p < 0.03) and hemodynamic performance (predicted ankle-brachial index with perfect outflow 0.82 after FFB vs 1.03 after AFB). On the basis of a detailed analysis of patient and graft risk factors, we could not explain the inferior patency rate of FFB, although our analysis suggested that inadequate inflow may contribute.

CONCLUSIONS

FFB is inferior to AFB as measured by patency and hemodynamic function. This inferior performance is independent of indications for FFB. AFB should remain the standard therapy for patients at low risk with iliac occlusive disease, but FFB provides adequate function and limb salvage in patients at high risk.