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Objectives: Endovascular therapy for aortoiliac occlusion (AIO) represents an increasingly implemented alternative therapy to open surgical bypass. However, a variety of endovascular strategies are currently used in complex (TASC C and D) cases of AIO with variable results. The purpose of this study is to review outcomes with a standardized approach utilizing brachial access (BA), balloon-assisted guidance (BAG), primary stenting and/or common femoral retrograde iliac endarterectomy (CFIE) for TASC C and D AIO.
Methods: A retrospective review was performed identifying consecutive patients undergoing endovascular therapy for AIO occlusion between 2009 and 2012. Medical records, non-invasive testing and angiographic imaging were reviewed for demographic data, clinical and operative variables. Kaplan-Meier estimates for patency and amputation-free survival were performed.
Results: A standardized endovascular approach for complex AOI was attempted in 46 symptomatic limbs in 36 consecutive patients. Preoperative ankle-brachial indices (ABI) were 0.41 and indication for operation was claudication 67% and critical limb ischemia 33% for all limbs. All patients had a variant of AIO (TASC D 81%, TASC C 19%). Technical success was 100% and no re-entry devices were required. Technical components utilized included BA in 35(76%) limbs, CFIE in 15(42%) limbs, primary stenting in all 46(100%) limbs, and BAG in 19(53%) patients. All common iliac arteries were treated with covered balloon expandable stents. There were no perforations or ruptures. Brachial complications occurred in 4(15%) patients all with 7 Fr. Sheaths. 30-day mortality is 0%. Mean follow-up for the cohort is 17.9 months (1-34 mos.). Primary patency at 12 and 24 months is 87% and 80% with secondary patency at 12 and 24 months being 94% and 90%. Freedom from amputation at 24 months is 95%.
Conclusions: This standardized approach using BA, BAG, primary stenting and CFIE for complex AIO produces excellent technical results that are reproducible. Patency and limb-salvage data are comparable to open reconstruction. Target vessel complications are minimal and access complications can be mitigated by using smaller diameter brachial sheaths. Continued application of this technique will impact the role for open surgery in complex AIO.