Extensive unilateral iliofemoral occlusions: durability of four techniques of arterial reconstructions

In patients with long unilateral iliofemoral occlusive disease unfit for percutaneous transluminal angioplasty (PTA), most surgeons would choose some type of prosthetic bypass (aortounifemoral, iliofemoral or cross over). All these bypasses would provide excellent early results, but some may not be sufficient in patients with a good life expectancy who also need durable patency. The purpose of the study was to compare the long-term results of four types of arterial reconstructions. Over 20 years, 468 unilateral iliofemoral occlusions were treated primarily by one of the following techniques: aortounifemoral bypass (group 1, n = 108), iliofemoral bypass (group 2, n = 144), crossover bypass (group 3, n = 108), and iliofemoral endarterectomy (group 4, n = 108). Patients in group 3 presented with more severe comorbidities, and patients in group 4 had more superficial femoral artery occlusions. All data were prospectively registered after discharge and during the survey. Patency was assessed with duplex ultrasonography on a yearly basis. Perioperative complications and death rates were similar in all groups. The standard error was less than 10% for a period of over 10 years in all groups, except for group 3, in which it was more than 10% after 8 years. At 8 years, primary patency rates in groups 1, 2, 3, and 4 were 79%, 66%, 74%, and 89%, respectively. The difference was significant between group 4 and group 2 (p < .02) and group 3 (p < .01). Secondary patency and limb salvage rates were not significantly different. In this study, for an equal perioperative risk, the primary patency rates of iliac endarterectomies were superior to those of the other techniques, suggesting that these procedures should be the first choice in patients in good physical condition. Iliofemoral bypasses and crossover bypasses needed much more redo surgery. A crossover bypass should be reserved for patients who are unfit for an abdominal approach or who have a short life expectancy.