A comparison between aortobifemoral bypass and aortoiliac kissing stents in patients with complex aortoiliac
Walter Dorigo1, Gabriele Piffaretti2, Filippo Benedetto3
1Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy.
Insights
Endovascular repair using kissing stents for aortoiliac lesions (TASC II C/D) shows comparable outcomes to aortobifemoral bypass. This minimally invasive approach offers similar early and late results with fewer complications.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Techniques
Background:
- Aortoiliac obstructive lesions, classified as TransAtlantic Inter-Society Consensus II (TASC II) C and D, pose significant management challenges.
- Traditional open surgical repair, such as aortobifemoral bypass, has been the standard, but carries inherent risks.
Purpose of the Study:
- To retrospectively compare the early and late outcomes of endovascular recanalization with kissing stents versus aortobifemoral bypass for TASC II C and D aortoiliac lesions.
- To evaluate the safety and efficacy of these two treatment modalities in a multicenter setting.
Main Methods:
- A multicenter retrospective study included 210 patients with TASC II C/D aortoiliac lesions from 2006-2013.
- Patients underwent either aortobifemoral bypass (n=82, group 1) or endovascular kissing stent repair (n=128, group 2).
- Outcomes including technical success, perioperative complications, survival, and patency rates were analyzed using statistical tests, including Kaplan-Meier curves and Cox regression.
Main Results:
- Endovascular repair (group 2) demonstrated a significantly lower rate of postoperative complications (7% vs. 20.5%).
- While not statistically significant (P=0.08), 6-year survival rates were higher in the endovascular group (83.5% vs. 65.5%).
- Primary, assisted primary, and secondary patency rates were similar between groups; critical limb ischemia was the only independent predictor of poorer primary patency.
Conclusions:
- Endovascular repair using the kissing stent technique is a safe and effective alternative for managing complex aortoiliac lesions (TASC II C/D).
- This approach yields comparable early and late results to open surgery, with a notable reduction in postoperative complications.
- The kissing stent technique represents a valuable option in the endovascular management of challenging aortoiliac disease.
Objective:
The aim of this study was to retrospectively compare early and late results of aortobifemoral bypass and endovascular recanalization with the kissing stent technique in the management of TransAtlantic Inter-Society Consensus II (TASC II) C and D lesions in the aortoiliac district in a multicenter study.
Methods:
From January 2006 to December 2013, 210 open and endovascular interventions for TASC II class C and D aortoiliac obstructive lesions were performed at three Italian teaching hospitals. In all the cases, the intervention was performed for aortic and bilateral iliac involvement. An aortobifemoral bypass was performed in 82 patients (group 1); in the remaining 128, an endovascular recanalization with the kissing stent technique was carried out (group 2). Early results in the two groups were compared with the χ2 test. Follow-up results were analyzed with Kaplan-Meier curves and compared with log-rank test. Univariate and multivariate (forward Cox regression) analysis to identify potentially significant predictors of primary patency in the whole study group was performed.
Results:
Patients in group 2 were more frequently female and more frequently had diabetes and arterial hypertension than patients in group 1. The indication for surgical intervention was the presence of critical limb ischemia in 29 cases in group 1 (35%) and in 31 cases in group 2 (24%; P = .07). Technical success in group 2 was 98.5%; two patients required immediate conversion to open surgery for iliac rupture. There was one perioperative death in group 1 (mortality rate, 1%; P = .2 in comparison with group 2). Four perioperative thromboses occurred, two in group 1 and two in group 2 (in one case requiring conversion to open surgical intervention), and no amputations at 30 days were recorded. Cumulative postoperative local and systemic complications occurred in 17 patients in group 1 (20.5%) and in 9 patients in group 2 (7%; P < .001). Mean duration of follow-up was 38 months (range, 1-96 months). Survival rates at 6 years were 65.5% (standard error [SE], 0.08) in group 1 and 83.5% (SE, 0.08) in group 2 (P = .08; log-rank, 2.2). At the same time interval, primary, assisted primary, and secondary patency rates were similar; reintervention rates were 6% in group 1 (SE, 0.05) and 11% in group 2 (SE, 0.04; P = .3; log-rank, 0.8). Univariate and multivariate analysis showed that only the presence of critical limb ischemia was independently associated with poorer primary patency during follow-up (hazard ratio, 2.4; 95% confidence interval, 0.9-6.4; P = .05).
Conclusions:
In this multicenter experience, endovascular repair of aortoiliac complex lesions with the kissing stent technique provided similar satisfactory early and late results to those obtained with open surgery.
