Minimally Invasive Management of Severe Aortoiliac Occlusive Disease

Peripheral arterial disease (PAD) is a complex and highly prevalent pathology. It has been estimated that ∼8.5 million people in the United States are affected by PAD, of which 12%-20% are older than age 60. The TransAtlantic Inter-Society Consensus (TASC) guidelines classified aortoiliac atherosclerotic disease based on morphology and level of lesions. TASC II guidelines recommend bilateral surgical bypass to the femoral arteries for TASC II C and D lesions. The aortobifemoral bypass (ABF) has been considered the gold standard in the treatment of aortoiliac occlusive disease (AIOD). The long-term patency rate of 85%-90% at 5 years and 75%-80% at 10 years has been for a long time unmatched by other methods of revascularization.

This is a review of the current literature regarding minimally invasive strategies in the care of TASC II C and D aortoiliac disease.

Endovascular therapies have led to a paradigm change even in the treatment of highly advanced lesions. Reconstruction of the aortic bifurcation for distal aortic and/or ostial unilateral/bilateral common iliac artery disease can be achieved via the deployment of stents with "kissing" technique and aortic endografts. Laparoscopic aortoiliac surgery for TASC II C and D lesions was first proposed in 1993. Total laparoscopic, laparoscopic-assisted, and laparobotic techniques have been described. Minimal incision aortic surgery (MIAS) describes abdominal incisions varying from 6 to 12 cm and positional adjustment of retractors to access the retroperitoneum for infrarenal aortic aneurysms and/or AIOD.

Although initial enthusiasm laparoscopic aortic surgery and MIAS have failed to gain acceptance in the vascular surgery community due to intrinsic procedural challenges, they are currently practiced in few highly specialized centers. At this moment, high-quality evidence is lacking regarding the further feasibility of these techniques and their applicability in general practice compared to endovascular therapies. While the ABF remains still the optimal choice in select, fit for surgery patients, endovascular therapies offer a less invasive approach that may provide a mortality and morbidity benefit in higher risk patients with acceptable short- and long-term outcomes.