Internal Iliac Artery Diameter Predicts Common-External Iliac Artery Patency Loss In Patients Undergoing Stenting For Occlusive Disease Of The Iliac Bifurcation
Andrew H. Smith, MD, Siddhartha Dash, BS, Erin C. Driscoll, BS, James Bena, MS, Levester Kirskey, MD, Jarrad Rowse, MD, David Hardy, MD, Sean P. Lyden, MD, Francis J. Caputo, MD, Christopher J. Smolock, MD.
Cleveland Clinic, Cleveland, OH, USA.
OBJECTIVES: Stent coverage of the internal iliac artery (IIA) origin is often required for treatment of occlusive disease at the iliac arterial bifurcation. In this study, we sought to determine patency rates of common-external iliac artery (C-EIA) stents and the IIA in patients requiring bare metal stent (BMS) coverage of the IIA origin. We hypothesized that stenosis and disease burden at the iliac artery bifurcation/IIA origin would compromise iliac runoff and negatively influence C-EIA patency.
METHODS: This is a single center, retrospective review of consecutive patients undergoing elective, endovascular treatment of aortoiliac disease (AIOD) between 2010 and 2018. Only patients with C-EIA BMS coverage of a patent IIA origin were included in the study. Patient variables and C-EIA stent patency were assessed. Analysis included Cox regression, Kaplan-Meier curves and receiver operator characteristics (ROC).
RESULTS: There were 338 limbs in 251 patients that met inclusion criteria for the study. AIOD was TASC C/D in 249/338 (73.7%) of cases. Primary C-EIA stent patency was 92.3±4.2% at three years and 82.1±10.3% at five years. Freedom from ipsilateral reintervention was 85.4±5.4% at three years and 80.8±7.4% at five years. Following coverage, immediate IIA occlusion was observed in 19/338 (5.6%) limbs. Decreasing luminal diameter of the IIA origin was predictive of immediate IIA occlusion (OR 0.40; 95% CI: 0.26, 0.61; p<0.01). IIA occlusion was significantly associated with an increased risk of ipsilateral C-EIA stent patency loss (HR 5.66; 95% CI: 1.35, 23.76; p=0.02). In univariable analysis, active tobacco use, recanalization of an occluded common iliac artery, age, creatinine, and decreasing luminal diameter of the IIA origin were significantly associated with loss of C-EIA stent primary patency. In multivariable analysis, only luminal diameter of the IIA origin predicted loss of C-EIA stent primary patency (HR 0.81; 95% CI, 0.68, 0.97; p=0.02). ROC analysis demonstrated that luminal diameter of the IIA origin predicted ipsilateral C-EIA reintervention with an area under the curve of 0.75 at five years.
CONCLUSIONS: Primary patency of C-EIA stents is high in patients requiring BMS coverage of the IIA origin. Luminal diameter of the IIA origin was strongly associated with loss of C-EIA and IIA patency with smaller diameters predicting reduced patency. These results may indicate a role for IIA origin intervention in patients undergoing stenting for AIOD.
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