Options in the surgical management of aorto-iliac occlusive disease: a changing perspective

The numerous options available for the treatment of aortoiliac occlusive disease have led to controversy over which is best. Not only are the technical aspects of direct aortoiliac reconstruction debated but the role of lower risk but less durable options such as extraanatomic bypass and balloon angioplasty and/or stenting is still unsettled. Rather than yield to the tendency to apply one method preferentially over the others, it is important to realize that each approach has a selective role to play in the overall management of aortoiliac occlusive disease, if applied in appropriate settings. In discussing these applications, the history of these controversies, and the pros and cons of each competitive approach are reviewed, along with the results of experiences with them by the author and others. While it is apparent that outcome data, stratified for location, and degree and extent of the occlusive disease being treated, are still needed for proper comparisons of some competitive techniques, especially balloon angioplasty and stenting, there is sufficient evidence to make certain general recommendations: endarterectomy should be limited to younger patients with soft atheromatous disease of the lower aorta and proximal iliac arteries; a femoral distal anastamosis is preferable to one at the iliac bifurcation; choice of proximal anastamosis should be based on the distribution of aortoiliac occlusive disease; concomitant profundaplasty is effective only if significant profunda narrowing is present (and not simply superficial femoral artery occlusion); the need for concomitant distal bypass can and should be predicted; axillobifemoral bypass should be limited to patients with 'prohibitive' risk or 'hostile' abdominal pathology; and, in view of the low risk and good long term patency of unilateral iliac bypasses, iliac PTA and stenting should not be extended to category III and IV lesions without demonstrating superior long term results for such lesions.