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The Management of Severe Aortoiliac Occlusive Disease: Endovascular Therapy Rivals Open Reconstruction
The Management of Severe Aortoiliac Occlusive Disease: Endovascular Therapy Rivals Open Reconstruction
Objective: Aortobifemoral bypass (ABF) grafting has been the traditional treatment for extensive aortoiliac occlusive
disease (AIOD). This retrospective study compared the outcomes and durability of recanalization, percutaneous
transluminal angioplasty, and stenting (R/PTAS) vs ABF for severe AIOD.
Methods: Between 1998 and 2004, 86 patients (161 limbs) underwent ABF (n ⴝ 75) or iliofemoral bypass (n ⴝ 11), and
83 patients (127 limbs) underwent R/PTAS. All patients had severe symptomatic AIOD (claudication, 53%; rest pain,
28%; tissue loss, 12%; acute limb ischemia, 7%). The analyses excluded patients treated for aneurysms, extra-anatomic
procedures, and endovascular treatment of iliac stenoses. Original angiographic imaging, medical records, and noninva-
sive testing were reviewed. Kaplan-Meier estimates for patency and survival were calculated and univariate analyses
performed. Mortality was verified by the Social Security database.
Results: The ABF patients were younger than the R/PTAS patients (60 vs 65 years; P ⴝ .003) and had higher rates of
hyperlipidemia (P ⴝ .009) and smoking (P < .001). All other clinical variables, including cardiac status, diabetes,
symptoms at presentation, TransAtlantic Inter-Society Consensus stratification, and presence of poor outflow were
similar between the two groups. Patients underwent ABF with general anesthesia (96%), often with concomitant
treatment of femoral or infrainguinal disease (61% endarterectomy, profundaplasty, or distal bypass). Technical success
was universal, with marked improvement in ankle-brachial indices (0.48 to 0.84, P < .001). Patients underwent R/PTAS
with local anesthesia/sedation (78%), with a 96% technical success rate and similar hemodynamic improvement (0.36 to
0.82, P < .001). At the time of R/PTAS, 21% of patients underwent femoral endarterectomy/profundaplasty or bypass
(n ⴝ 5) for concomitant infrainguinal disease. Limb-based primary patency at 3 years was significantly higher for ABF
than for R/PTAS (93% vs 74%, P ⴝ .002). Secondary patency rates (97% vs 95%), limb salvage (98% vs. 98%), and
long-term survival (80% vs 80%) were similar. Diabetes mellitus and the requirement of distal bypass were associated with
decreased patency (P < .001). Critical limb ischemia at presentation (tissue loss, hazard ratio [HR], 8.1; P < .001), poor
outflow (HR, 2; P ⴝ .023), and renal failure (HR, 2.5; P ⴝ .02) were associated with decreased survival.
Conclusion: R/PTAS is a suitable, less invasive alternative to ABF for the treatment of severe AIOD. Repair of the
concomitant femoral occlusive disease is often needed regardless of open or endovascular treatment. Infrainguinal disease
negatively affects the durability of the procedure and patient survival. ( J Vasc Surg 2008;48:1451-57.)
Extensive aortoiliac occlusive disease (AIOD) often re- means, with high technical success rates and low morbidity.
sults in debilitating symptoms and limb-threatening symp- This has been mirrored by a decreasing number of patients
toms in the setting of multilevel occlusive disease. The treat- undergoing ABF.2,3 Treatment of aortoiliac occlusions, de-
ment of AIOD remains gratifying for the patient and fined as TransAtlantic Inter-Society Consensus (TASC) B
surgeon.1 Operative or endovascular treatment often results in or higher,4 remains a more challenging endovascular treat-
rapid symptom abatement, clearly discernible hemodynamic ment modality than the treatment of iliac stenoses.
changes, and durable prevention of recurrent symptoms. Endovascular treatment for AIOD has become more
Severe AIOD traditionally has been treated with aorto- frequent with the realization that it is safe and the durability
bifemoral bypass (ABF). However, endovascular therapies of the procedure is acceptable. Furthermore, endovascular
for arterial occlusive disease have evolved, leading to the procedures in the proximal arterial beds appear to have
preferential treatment of iliac stenoses by using endovascular
greater durability than endovascular treatment of the distal
From the Departments of Vascular Surgery,a and Quantitative Health
arteries. Lastly, endovascular procedures are often used as
Sciences,b The Cleveland Clinic. first-line therapy for AIOD because many believe that
Competition of interest: none. operative options are not lost, even if the endovascular
Presented in part at the 2007 Annual Vascular Meeting, Baltimore, Md, Jun therapy is unsuccessful. Still, many questions remain about
7-10, 2007.
Additional material for this article may be found online at www.jvascsurg.org. this evolving treatment paradigm.
Reprint requests: Vikram S. Kashyap, MD, Cleveland Clinic Foundation, The purpose of this study was to review our contem-
Department of Vascular Surgery, S40, 9500 Euclid Ave, Cleveland, OH porary experience treating AIOD with open reconstruction
44195 (e-mail: kashyav@ccf.org).
and compare the results with endovascular therapy during
0741-5214/$34.00
Copyright © 2008 by The Society for Vascular Surgery. the same time interval. Particular attention was paid to
doi:10.1016/j.jvs.2008.07.004 periprocedural safety, technical outcome, midterm proce-
1451
JOURNAL OF VASCULAR SURGERY
1452 Kashyap et al December 2008
dural durability for both open and endovascular treatment abling claudication, rest pain, and presence of tissue loss
modalities, and patient survival. (gangrene or ulceration).
Operative technique. Both ABF and R/PTAS proce-
METHODS dures were performed by the faculty of The Cleveland
Patients. After Institutional Review Board approval, a Clinic Department of Vascular Surgery. The ABF proce-
retrospective review was performed of patients at the Cleve- dures were preferentially performed using a transperitoneal
land Clinic Foundation (CCF) from Jul 1, 1998, to Dec 31, approach. End-to-end proximal anastomoses were used in
2004, who underwent an open or endovascular procedure 76% of ABF cases unless bilateral external iliac occlusions or
for symptomatic AIOD. During this time, 86 patients other anatomic constraints dictated an end-to-side proxi-
underwent ABF (n ⫽ 75) and iliofemoral bypass (n ⫽ 11) mal anastomosis. Bifurcated Dacron prostheses were used
for treatment of severe AIOD supplying blood flow to 161 with spatulated end-to-side distal anastomoses. Percutane-
limbs, and 83 patients underwent recanalization and per- ous procedures were performed in dedicated endovascular
cutaneous transluminal angioplasty and stenting (R/ suites with the capability to perform concomitant open
PTAS) supplying blood flow to 127 symptomatic limbs (44 vascular procedures, as previously described.5
bilateral, 39 unilateral). We recently showed that R/PTAS The most common technique for recanalization of an
was technically feasible and safe for iliac occlusions in 89 occlusion was either intraplaque or subintimal passage of a
consecutive patients.5 This study includes many of the hydrophilic wire and catheter through antegrade or retro-
patients previously reported in the endovascular group but grade approaches (Fig 1, online only). Re-entry devices
extends the follow-up interval and focuses on comparing were not routinely used. Of significance, open endarterec-
open vs endovascular results based on limbs treated. tomy and patch angioplasty were performed when disease
Over time, R/PTAS has overtaken ABF as the prefer- extended into the common femoral artery. In general,
ential treatment for severe AIOD at CCF. In the first year of primary stenting of iliac occlusions was predominantly per-
this experience, 15 ABFs and one R/PTAS were per- formed with self-expanding nitinol stents except in cases of
formed. However, in the last year, 10 ABFs and 22 common iliac artery orificial occlusions, where balloon-
R/PTAS procedures were performed. Of note, patients expandable stents were used.
with AIOD represented a small fraction of all patients being Data analysis and statistical methods. Periprocedural
treated for peripheral atherosclerotic occlusive disease. The data, associated morbidity, and mortality ⱕ30 days of the
number of ABFs performed fell after 2004, precluding a procedure were determined. Follow-up documentation of
meaningful contemporary comparison. patency of the treated aortoiliac lesion included the pres-
All clinical, perioperative, and demographic data were ence of palpable femoral/distal artery pulses, resolution of
obtained through review of original hospital and physician symptoms, or noninvasive vascular laboratory testing, or a
records, including data collected prospectively in a depart- combination of these. The last included ankle-brachial
mental registry. The original angiographic imaging was re- indices (ABIs), pulse-volume recordings, and color-flow
viewed by captured and stored electronic images (MagicView, Doppler ultrasound scans.
Siemens, Erlangen, Germany) to confirm the diagnosis of We were able to obtain reliable follow-up data for 81 of
complete aortic (n ⫽16 in the R/PTAS group) or iliac 86 ABF patients (94%) and for 72 of 83 R/PTAS patients
occlusion and stratify by TASC criteria. Only patients with (87%). The average length of follow-up was 21 months.
native symptomatic complete aortic or iliac occlusion Primary and secondary patency and limb salvage were de-
(TASC-B or higher) requiring recanalization as a part of termined in concordance with the Society for Vascular
their endovascular treatment were included. Patients with Surgery guidelines.6 Loss of patency was determined by the
acute limb ischemia with thrombosis in the setting of native loss of previously palpable pulses, patients presenting with
chronic AIOD were included. The analysis excluded pa- recurrent symptoms, a drop in ABI ⬎0.15, Doppler ultra-
tients undergoing endovascular treatment such as PTA or sound findings, or a combination of these findings. Failures
stenting for iliac stenoses. Also excluded were patients with underwent repeat angiography.
iliac dissection, an associated abdominal aortic aneurysm Categoric factors were summarized by frequency and
(AAA), or iliac recanalization before or during AAA en- percentage, and continuous measure distributions were
dograft placement. described using the mean. Comparisons of categoric mea-
Preoperative demographic data were obtained, includ- sures were performed on both the limb- and person-level
ing gender, risk factors, and symptoms. Coronary artery using 2 tests and Fisher exact tests when numbers of
disease was characterized as patients with no active disease patients were small for a given level. Age differences be-
(low risk), optimized cardiac function (intermediate risk), tween groups were compared using t tests.
or active disease with angina or heart failure (high risk). Survival, limb salvage, and patency were summarized
Hyperlipidemia included patients with this diagnosis or using Kaplan-Meier estimates and 95% confidence limits
who were being treated for elevated plasma lipids (usually overall, and by treatment group. Estimates of survival and
with statins), or both. Patients characterized as having patency are shown at 1, 2, and 3 years. Mortality was
kidney dysfunction included elevated serum creatinine con- verified by the Social Security Death Index database. Mar-
centration (⬎1.5 mg/dL) and dialysis-dependent status. ginal Cox proportional hazard models were used to assess
Chronic limb ischemia symptoms were stratified into dis- the relative risk (hazard ratios [HR]) between groups in
JOURNAL OF VASCULAR SURGERY
Volume 48, Number 6 Kashyap et al 1453
Table I. Preoperative clinical factors for patients Table II. Perioperative results for patients undergoing
undergoing aortobifemoral bypass, or recanalization, aortobifemoral bypass or recanalization, percutaneous
percutaneous transluminal angioplasty, and stenting for transluminal angioplasty and stenting for extensive
extensive aortoiliac occlusive disease aortoiliac occlusive disease
Table V. Univariate analyses of selected variables examined for association with survival for all patients with severe
aortoiliac occlusive disease undergoing aortobifemoral bypass or recanalization, percutaneous transluminal angioplasty,
and stenting
estingly, patients with TASC-D lesions had a 3-year series and the limited failures. After adjusting for other
patency of 90%, much higher than either TASC-B or -C selected variables, loss of primary patency was associated
groups (P ⫽ .025). Univariate analyses were also performed with revascularization using R/PTAS compared with ABF
for variables associated with secondary patency and limb (HR, 4.6; P ⬍ .001) and insulin-dependent diabetes mel-
salvage but did not reveal further information given the litus (HR, 9.7; P ⬍ .001). Also, patients undergoing a
small sample size and limited failures. concomitant distal bypass at the time of aortoiliac revascu-
Survival of this cohort with severe AIOD was examined larization were associated with a loss of primary patency of
(Table V). Interestingly, the diagnosis or treatment (mostly the aortoiliac segment (HR, 5.6; P ⫽ .010). For overall
with statins) of hyperlipidemia, or both, was associated with survival, multivariable analyses indicated that worsening
increased 3-year survival (90% vs 68%; HR, 0.4; P ⫽ .005). renal function (creatinine ⬎2.5 mg/dL) adversely affected
Patients with renal failure (59% vs 83%, HR 2.5, P ⫽ .02), survival (HR, 12.2; P ⫽ .015). Poor outflow, as defined by
and poor outflow (71 vs. 84%, HR 2.0, P ⫽ .023) were superficial femoral artery occlusion, was associated with
associated with decreased survival rates. Patients with in- diminished survival (HR, 2.1; P ⫽ .025), whereas hyper-
creasing severity of the initial presenting symptom were lipidemia (and statin treatment) was significantly associated
clearly associated with decreasing survival rates. Patients with increased survival (HR, 0.38; P ⫽ .003).
with claudication had survival of 91% at 3 years, whereas
patients with rest pain (77%, HR, 2.5) and tissue loss (63%, DISCUSSION
HR, 8.1) had lower rates (P ⬍ .001). Presenting with acute We believe this is the first contemporary study of open
limb ischemia in a small group of patients was associated revascularization vs endovascular treatment of AIOD. Dur-
with a 3-year survival of only 34%. There was a trend ing this 6-year interval, we had a balanced use of both open
towards decreased survival in patients with worsening dia- and endovascular treatment of AIOD in the same group of
betes mellitus status. Other variables examined, including vascular surgeons. Despite the nonrandomized nature of
age, gender, cardiac status, smoking history, TASC classi- this study, the two groups undergoing ABF and R/PTAS
fication, and type of anesthesia, had changes in survival were well matched in number and other salient clinical
rates that were not statistically significant. variables. The TASC consensus statement, recently up-
We carefully explored multivariable modeling, but dated in 2007, provides a framework to assess the treatment
these analyses were limited by the number of patients in this of aortoiliac lesions by stratifying lesion length and mor-
JOURNAL OF VASCULAR SURGERY
1456 Kashyap et al December 2008
phology.4,7 Importantly in the present series, TASC classi- endovascular treatment of complex aortoiliac occlusions
fications were the same in both groups, indicating that the reveals the primary patency is 69% to 76% at 2 years, with
burden of occlusive disease was similar in both groups and secondary patency rates of 85% to 95% at 2 years.12-15
that easier, less extensive cases were not reserved for endo- Furthermore, overall complication rates were low in recent
vascular treatment. series (1.4% to 4.8%), likely due to improvements in tech-
Patients undergoing R/PTAS were older but had sim- nique and device technology. In a series of 212 patients
ilar clinical variables as patients undergoing ABF. Most with chronic iliac occlusions, successful recanalization was
underwent the procedure under local anesthesia, with high accomplished in nearly 90%, with nearly all patients show-
levels of technical and hemodynamic success. Primary pa- ing with marked clinical improvement.16 Primary patency
tency for R/PTAS was lower, but all other long-term at 4 years was 75.7%, similar to our experience.
measures, including secondary patency, limb salvage, and Despite a large literature on ABF, most articles were
survival, were similar to patients undergoing ABF. Patency written in the 1970s and 1980s, before endovascular ther-
was affected by insulin-dependent diabetes mellitus. Sur- apy began supplanting much of the volume for open recon-
prisingly, patients undergoing R/PTAS with TASC-D le- struction.17 The most extensive review of data on morbid-
sions were associated with better patency. This may indicate ity and mortality of open ABF was done by de Vries and
that there was better recognition of the extent of disease, Hunink in 1997.18 A meta-analysis of 25 articles demon-
leading to more complete revascularization using PTAS. strated a cumulative 4.4% mortality rate and 12.2% compli-
Regardless, all patients undergoing R/PTAS may benefit cation rate. A subgroup analysis showed a decrease in
from postoperative surveillance to identify restenosis. mortality and complication rates to 3.3% and 8.3%, respec-
A concomitant distal bypass was performed selectively tively, in more recent time intervals. The overall 5-year
in patients with severe multilevel disease, as applied in other patency rate was 91% for patients with claudication and 87%
institutions.8 However, patients who required concomitant for patients with critical limb ischemia. The recognition
distal revascularization along with either ABF or R/PTAS that addressing profunda femoris orificial lesions leads to
had dismal patency rates, perhaps indicating a more virulent improved ABF graft patency has been highlighted by pre-
atherosclerotic process. vious authors.19
Survival was better in patients with hyperlipidemia, Hertzer recently reviewed a 28-year personal experi-
most of whom were receiving statin therapy. Renal failure, ence with direct and extra-anatomic reconstruction for
increasing severity of presenting symptoms, and poor out- AIOD at The Cleveland Clinic.20 Of note, this experience
flow were associated with decreased survival, the latter two entailed an interval from 1976 to 2002, with only a handful
again reflecting the atherosclerotic burden in a patient. of patients included in the current analyses. Perioperative
Some technical issues are worthy of discussion. Recan- mortality was 2.3% after direct reconstruction, 5.6% after
alization of heavily calcified vessels can be challenging. femorofemoral bypass, and 12% after axillofemoral bypass.
Ensuring catheter delivery to the true lumen both above Direct reconstruction with aortofemoral or aortoiliac by-
and below the recanalized segment is critical to successful pass led to durable patency rates of 85% at 5 years and 77%
therapy. Preoperative duplex ultrasound imaging or com- at 10 years. Extra-anatomic bypass and younger patients
puted tomography angiography allows delineation of pa- were associated with decreased patency rates. The finding
tients with femoral atherosclerotic disease that requires that younger patients have poorer durability after ABF has
alternatives to local anesthesia to allow femoral endarterec- been corroborated by Reed et al.21 They found that pa-
tomy and reconstruction. In the early years of this experi- tients aged ⬍50 years had 5-year patency rates of 66% vs
ence, thrombolysis was used in selected patients to decrease 87% for patients aged 50 to 59 years and 96% for those aged
the chronic thrombus burden before recanalization, angio- ⬎60 years. This significant difference was thought to be
plasty, and stenting. This has largely been abandoned and is secondary to a more virulent atherosclerotic process, espe-
reserved only for patients with acute limb ischemia and cially in the infrainguinal vessels, and smaller aortic size.
evidence of acute thrombosis. Multilimb access is often Interestingly, survival was approximately 90% at 5 years and
required, with brachial artery access occupying an increas- comparable in the three age groups. The younger patient
ing role in current procedures. Systemic heparinization with AIOD may require repeat intervention after initial
during the procedure and antiplatelet therapy after the successful ABF given the long-term survival and ongoing
procedure for 3 to 6 months is routine. atherosclerotic process.
Aortoiliac occlusions are more complex and challeng- Limitations of our study are worthy of mention. This is
ing than stenoses to treat with endovascular means, and a retrospective, nonrandomized study in a referral center
endovascular treatment has been assumed to be of limited where many of the patients are from out-of-state and
durability in this setting. Initial attempts at iliac recanaliza- international locations; thus, consistent follow-up is ex-
tion for iliac occlusions were complicated by significant tremely difficult. Nevertheless, most of the patients that
embolization, prompting many to question the usefulness followed up with us at 1 year were also seen in subsequent
of this technique.9,10 However, chronic occlusions of the years of follow-up, allowing assessment of midterm dura-
iliac artery can represent 13% or more of the lesions en- bility and survival at 3 years. Longer follow-up is ideal and
countered in large series of endovascular management of may reveal data that alter our current conclusions. In addi-
iliac lesions.11 Since 1995, review of the published data on tion, clinical variables (ie, smoking) affecting outcome may
JOURNAL OF VASCULAR SURGERY
Volume 48, Number 6 Kashyap et al 1457
have been inconsistently reported in the patient record. 2. Whiteley MS, Ray-Chaudhuri SB, Galland RB. Changing patterns in
Mortality, however, was verified by using the Social Secu- aortoiliac reconstruction: a 7-year audit. Br J Surg 1996;83:1367-9.
3. Upchurch GR, Dimick JB, Wainess RM, Eliason JL, Henke PK, Cowan
rity Death Index database, which allowed a robust survival JA, et al. Diffusion of new technology in health care: the case of
analysis. The choice of ABF vs R/PTAS was left to the aorto-iliac occlusive disease. Surgery 2004;136:812-8.
surgeon treating the patient, leading to inherent biases. 4. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes
Clinical testing was not standardized and left to the discre- FG. Inter-Society Consensus for the Management of Peripheral Arterial
tion of the treating physician. Thus, all patients did not Disease (TASC II). J Vasc Surg 2007;45(suppl S):S5-67.
5. Leville CD, Kashyap VS, Clair DG, Bena JF, Lyden SP, Greenberg RK,
have ABI, duplex imaging, or other noninvasive imaging et al. Endovascular management of iliac artery occlusions: extending
along with physical examination findings at follow-up. Ide- treatment to TransAtlantic Inter-Society Consensus class C and D
ally, a randomized controlled trial comparing open and patients. J Vasc Surg 2006;43:32-9.
endovascular treatment of AIOD is needed to minimize 6. Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et
al. Recommended standards for reports dealing with lower extremity
confounding variables. Given the preference for less inva-
ischemia: revised version. J Vasc Surg 1997;26:517-38.
sive therapies, this could be a difficult trial to complete with 7. Dormandy JA, Rutherford RB. Management of peripheral arterial dis-
regards to patient recruitment and enrollment. ease (PAD). TASC Working Group. TransAtlantic Inter-Society Con-
census (TASC). J Vasc Surg 2000;31:S1-S296.
CONCLUSIONS 8. Dalman RL, Taylor LM, Jr, Moneta GL, Yeager RA, Porter JM.
Simultaneous operative repair of multilevel lower extremity occlusive
Despite these limitations, our current results demon-
disease. J Vasc Surg 1991;13:211-9.
strate an increasing ability by a multiphysician vascular 9. Ring EJ, Freiman DB, McLean GK, Schwarz W. Percutaneous recana-
surgery group to treat extensive iliac disease by endovascu- lization of common iliac artery occlusions: an unacceptable complica-
lar means. The treatment of AIOD can be accomplished tion rate? AJR Am J Roentgenol 1982;139:587-9.
with either open or endovascular means with excellent 10. Leu AJ, Schneider E, Canova CR, Hoffmann U. Long-term results after
recanalisation of chronic iliac artery occlusions by combined catheter
technical success. Primary patency is significantly better therapy without stent placement. Eur J Vasc Endovasc Surg 1999;18:
with open reconstruction, but secondary patency, limb 499-505.
salvage, and survival are nearly equivalent between groups. 11. Johnston KW. Iliac arteries: reanalysis of results of balloon angioplasty.
Extensive lesions do not preclude successful endovascular Radiology 1993;186:207-12.
treatment. An aggressive posture to surgically treat the 12. Dyet JF, Gaines PA, Nicholson AA, Cleveland T, Cook AM, Wilkinson
AR, et al. Treatment of chronic iliac artery occlusions by means of
concomitant femoral lesions that are often encountered in percutaneous endovascular stent placement. J Vasc Interv Radiol 1997;
patients with iliac occlusive disease is required for AFBF 8:349-53.
patients as well as those undergoing R/PTAS. However, 13. Henry M, Amor M, Ethevenot G, Henry I, Mentre B, Tzvetanov K.
caution in adding a concomitant distal bypass may be Percutaneous endoluminal treatment of iliac occlusions: long-term
follow-up in 105 patients. J Endovasc Surg 1998;5:228-35.
warranted. Endovascular treatment is a suitable alternative
14. Uher P, Nyman U, Forssell C, Lindh M, Lindblad B, Ivancev K.
for extensive AIOD and can be accomplished in a less Percutaneous placement of stents in chronic iliac and aortic occlusive
invasive manner, with most midterm outcomes comparable disease. Eur J Vasc Endovasc Surg 1999;18:114-21.
with open reconstruction. 15. Carnevale FC, De BM, Merino S, Egana JM, Caldas JG. Percutaneous
endovascular treatment of chronic iliac artery occlusion. Cardiovasc
We thank Dr Sunita Srivastava for her assistance with Intervent Radiol 2004;27:447-52.
this clinical project. 16. Scheinert D, Schroder M, Ludwig J, Braunlich S, Mockel M, Flachska-
mpf FA, et al. Stent-supported recanalization of chronic iliac artery
AUTHOR CONTRIBUTIONS occlusions. Am J Med 2001;110:708-15.
17. Rutherford RB. Options in the surgical management of aorto-iliac occlu-
Conception and design: VK, MP, TS, DG sive disease: a changing perspective. Cardiovasc Surg 1999;7:5-12.
Analysis and interpretation: VK, MP, JB, TS, PO, SL, DG 18. de Vries SO, Hunink MG. Results of aortic bifurcation grafts for aortoiliac
Data collection: VK, MP, JB occlusive disease: a meta-analysis. J Vasc Surg 1997;26:558-69.
Writing the article: VK, MP 19. Brewster DC, Darling RC. Optimal methods of aortoiliac reconstruc-
tion. Surgery 1978;84:739-48.
Critical revision of the article: VK, JB, TS, PO, SL, DG
20. Hertzer NR, Bena JF, Karafa MT. A personal experience with direct
Final approval of the article: VK, MP, JB, TS, PO, SL, DG reconstruction and extra-anatomic bypass for aortoiliofemoral occlusive
Statistical analysis: VK, JB disease. J Vasc Surg 2007;45:527-35.
Obtained funding: Not applicable 21. Reed AB, Conte MS, Donaldson MC, Mannick JA, Whittemore AD,
Overall responsibility: VK Belkin M. The impact of patient age and aortic size on the results of
aortobifemoral bypass grafting. J Vasc Surg 2003;37:1219-25.
REFERENCES
1. Bosch JL, van der GY, Hunink MG. Health-related quality of life after Submitted May 14, 2008; accepted Jul 9, 2008.
angioplasty and stent placement in patients with iliac artery occlusive
disease: results of a randomized controlled clinical trial. The Dutch Iliac Additional material for this article may be found online
Stent Trial Study Group. Circulation 1999;99:3155-60. at www.jvascsurg.org.
JOURNAL OF VASCULAR SURGERY
1457.e1 Kashyap et al December 2008
Table III (online only). Kaplan-Meier estimates of patency, limb salvage, and survivala at 1, 2, and 3 years are provided
overall and by treatment group
Table IV (online only). Univariate analyses of selected variables examined for association with primary patency
Variable Group Limbs, No. 3-year, % (95% CI) HR (95% CI) P vs reference groupa P overalla
Age ⬍60 y
All No 167 83 (74-92) 1.0 .37
Yes 102 85 (76-95) 1.4 (0.7-2.7)
ABFB No 76 92 (85-99) 1.0 .82
Yes 68 94 (85-100) 0.9 (0.2-3.3)
R/PTAS No 91 75 (60-90) 1.0 .034
Yes 34 71 (53-90) 2.2 (1.1-4.6)
Female gender
All No 167 81 (71-91) 1.0 .86
Yes 102 86 (79-94) 0.9 (0.4-2.0)
ABFB No 94 93 (86-100) 1.0 .70
Yes 50 91 (82-99) 0.7 (0.2-3.5)
R/PTAS No 73 71 (56-87) 1.0 .13
Yes 52 81 (66-95) 1.8 (0.8-3.7)
Diabetes
All None 207 86 (79-93) 1.0 ⬍.001
NIDDM 50 84 (69-99) 1.5 (0.6-3.8) .36
IDDM 10 NEb 7.4 (2.8-19.6) ⬍.001
ABFB None 105 95 (91-100) 1.0 ⬍.001
NIDDM 29 97 (90-100) 0.8 (0.1-6.9) .84
IDDM 8 0.00 (0-0) 11.6 (3.6-37.6) ⬍.001
R/PTAS None 102 74 (60-89) 1.0 ⬍.001
NIDDM 21 72 (47-97) 1.5 (0.7-3.5) .34
IDDM 2 NEb 5.3 (2.8-10.0) ⬍.001
Smoking
All No 79 77 (64-89) 1.0 .18
Yes 160 85 (77-94) 0.6 (0.3-1.3)
ABFB No 14 92 (78-100) 1.0 .86
Yes 102 92 (85-98) 1.2 (0.1-13.9)
R/PTAS No 65 74 (60-88) 1.0 .59
Yes 58 75 (55-94) 0.8 (0.4-1.7)
TASC
All B 52 79 (63-94) 1.0 .047
C 69 76 (62-90) 1.0 (0.4-2.1) .91
D 134 90 (82-98) 0.3 (0.1-0.9) .03
ABFB B 32 96 (88-100) 1.0 .60
C 32 91 (80-100) 0.8 (0.2-3.6) .81
D 66 90 (79-100) 0.4 (0.1-2.7) .33
R/PTAS B 20 53 (22-84) 1.0 .025
C 37 61 (36-86) 0.8 (0.3-1.8) .51
D 68 90 (79-100) 0.2 (0.1-0.7) .01
Poor outflow
All No 165 85 (77-93) 1.0 .83
Yes 94 82 (71-92) 1.1 (0.5-2.3)
ABFB No 80 95 (89-100) 1.0 .66
Yes 56 90 (80-100) 1.3 (0.4-4.5)
R/PTAS No 85 77 (64-90) 1.0 .56
Yes 38 66 (41-91) 1.3 (0.5-3.1)
Femoral management
All Native 157 81 (72-90) 1.0 .027
Uni CFA 43 87 (70-100) 0.4 (0.1-1.2) .11
Bi CFA 50 95 (89-100) 0.4 (0.1-1.3) .12
Bypass 17 59 (24-94) 3.1 (0.9-10.6) .07
ABFB Native 57 95 (88-100) 1.0 ⬍.001
Uni CFA 28 100 (100-100) NEb ⬍.001
Bi CFA 46 95 (88-100) 1.2 (0.3-5.1) .80
Bypass 11 61 (25-97) 7.4 (1.4-38.1) .02
R/PTAS Native 100 74 (61-87) 1.0 ⬍.001
Uni CFA 15 67 (32-100) 0.3 (0.1-1.6) .16
Bi CFA 4 NEb NEb ⬍.001
Bypass 6 NEb 2.4 (0.3-20.0) .41
ABF, aortobifemoral bypass; Bi CFA, bilateral common femoral endarterectomy and/or profundaplasty; CI, confidence intervals; HR, hazard ratios; IDDM,
insulin-dependent diabetes mellitus; NIDDM, non-insulin-dependent diabetes mellitus; Uni CFA, unilateral common femoral endarterectomy and/or
profundaplasty; R/PTAS, recanalization, percutaneous transluminal angioplasty, and stenting.
a
P values are testing whether hazard ratios ⫽ 1.
b
Not estimable secondary to small numbers at that time point.
JOURNAL OF VASCULAR SURGERY
1457.e3 Kashyap et al December 2008
Fig 1 (online only). A, Transbrachial aortography documents an aortic occlusion in a 68-year old woman with rest
pain. Late images document the presence of distal iliac arteries reconstituted via collaterals (not shown) B, Femoral
access is obtained with ultrasound guidance and endovascular recanalization is performed using a hydrophilic guidewire
and catheter. Primary stenting using self-expanding nitinol stents with postdeployment balloon angioplasty restores
normal pulsatile perfusion to both lower extremities. Bottom panels, Inaudible Doppler signals preoperatively to
ankle-brachial indices of 1.0 bilaterally, transmetatarsal and digital waveforms are shown.