Long-term Results of Extensive Aortoiliac Occlusive Disease (EAIOD) Treated by Endovascular Therapy and Risk Factors for Loss of Primary Patency

Long-term Results of Extensive Aortoiliac Occlusive Disease (EAIOD) Treated by Endovascular Therapy and Risk Factors for Loss of Primary Patency

Introduction
Aortoiliac occlusive disease (AIOD) has historically been treated with aortobifemoral (ABF) bypass due to its satisfactory primary patency rates, ranging between 85–90% at 5 years and 75–85% at 10 years. However, ABF bypass is associated with substantial perioperative mortality and morbidity, up to 17–32% and 12.2–32.0%, respectively. With advancements in endovascular devices and increased experience among vascular surgeons, endovascular techniques have emerged as a minimally invasive alternative, offering reduced mortality and morbidity compared to ABF bypass. While endovascular therapy is firmly established as the first-line treatment for focal AIOD, its efficacy for extensive and complex AIOD, classified as TransAtlantic Inter-Society Consensus II (TASC II) C and D lesions, remains controversial. This study aims to evaluate the long-term outcomes of endovascular therapy for extensive aortoiliac occlusive disease (EAIOD) and identify risk factors associated with the loss of primary patency.

Methods
This retrospective cohort study included patients diagnosed with TASC II C and D AIOD lesions who underwent endovascular treatment between January 2008 and June 2018. Demographic, diagnostic, procedural, and follow-up data were collected and analyzed. Technical success was defined as residual stenosis of less than 30% on intraoperative angiography. Patients were followed up with ankle-brachial index (ABI) measurements, Doppler ultrasound, or computed tomography angiography (CTA) at 3, 6, 9, and 12 months, and annually thereafter. Significant restenosis was defined as a peak systolic velocity ratio greater than 2.4 on duplex ultrasound, greater than 50% stenosis on angiography or CTA, or a decrease of 0.2 or more in resting ABI. Loss of primary patency was defined as a decrease in ABI associated with significant restenosis or occlusion requiring reintervention.

Univariate and multivariate logistic regression analyses were performed to identify risk factors for the loss of primary patency. Kaplan-Meier analysis was used to calculate primary and secondary patency rates, as well as survival rates at 5 and 10 years.

Results
A total of 148 patients with 173 limbs underwent endovascular treatment for EAIOD. The technical success rate was 88.5%. The mean age of the patients was 68.6 years, with a male-to-female ratio of 11:1. Among the patients, 39.2% had TASC II C lesions, and 60.8% had TASC II D lesions. The mean follow-up duration was 79.2 months.

Primary patency rates were 82.1% at 5 years and 74.8% at 10 years, while secondary patency rates were 89.4% at 5 years and 83.1% at 10 years. The 5-year survival rate was 84.2%. Perioperative complications occurred in 15.8% of patients, with arterial dissection being the most common complication (5.4%). Other complications included femoral pseudoaneurysm (3.0%), iliac artery perforation (1.4%), stent graft infection (1.4%), distal embolism (1.4%), postoperative kidney failure (3.0%), myocardial infarction (3.4%), access site hematoma (3.0%), and access site infection (0.7%).

Univariate analysis revealed significant differences in age, TASC II classification, infrainguinal lesions, critical limb ischemia (CLI), and smoking between patients with and without loss of primary patency. Multivariate logistic regression identified age less than 61 years (adjusted odds ratio [aOR]: 6.47; 95% CI: 1.47–28.36; P = 0.01), CLI (aOR: 7.81; 95% CI: 1.92–31.89; P = 0.04), and smoking (aOR: 10.15; 95% CI: 2.79–36.90; P < 0.01) as independent risk factors for the loss of primary patency.

Discussion
Endovascular therapy has emerged as a viable alternative to ABF bypass for EAIOD, particularly for patients with TASC II C and D lesions. The study demonstrated encouraging long-term patency and survival rates, with primary patency rates of 82.1% at 5 years and 74.8% at 10 years, comparable to those of ABF bypass. The perioperative morbidity rate of 15.8% was lower than that reported for open surgery, highlighting the safety of endovascular therapy.

Age less than 61 years was identified as a significant risk factor for the loss of primary patency, consistent with previous studies suggesting that younger patients with AIOD exhibit more aggressive disease progression. Smoking was another independent risk factor, underscoring the detrimental effects of smoking on endothelial function and atherosclerosis progression. CLI, a marker of severe atherosclerosis, was also associated with a higher risk of primary patency loss, likely due to poorer collateral circulation and the need for simultaneous distal revascularization.

The study also highlighted the importance of the kissing technique and the use of covered stents in complex lesions. The femoral-femoral crossover reconstruction was effective in cases where contralateral recanalization failed, demonstrating the versatility of endovascular approaches.

Limitations
This study has several limitations. First, its retrospective nature introduces potential selection bias. Second, restenosis was evaluated using non-invasive methods such as ultrasound and CTA rather than angiography, which may affect the accuracy of the findings. Third, the procedures were performed by multiple surgeons over a decade, which may have introduced variability in decision-making and technique.

Conclusion
Endovascular therapy is an effective treatment for EAIOD, offering satisfactory long-term patency and survival rates. Age less than 61 years, CLI, and smoking are independent risk factors for the loss of primary patency. These findings support the use of endovascular therapy as a first-line treatment for EAIOD, particularly in patients with complex lesions who are at high risk for open surgery.

doi.org/10.1097/CM9.0000000000001229

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