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Trans-Atlantic Inter-Society Consensus Class D Aortoiliac Lesions: A Comparison of Endovascular and Open Surgical
Joshua A Gabel1,2, Sharon C Kiang1,2, Ahmed M Abou-Zamzam1
1Department of Surgery, Division of Vascular Surgery, Loma Linda University School of Medicine, Loma Linda, CA.
Insights
For Trans-Atlantic Inter-Society Consensus class D (TASC II D) aortoiliac occlusive disease (AIOD), endovascular reconstruction offers comparable outcomes to surgical bypass. This approach is particularly beneficial for high-risk patients due to its reduced operative risk.
Area of Science:
- Vascular Surgery
- Endovascular Interventions
- Aortoiliac Occlusive Disease
Background:
- Trans-Atlantic Inter-Society Consensus class D (TASC II D) aortoiliac occlusive disease (AIOD) presents complex treatment challenges.
- Treatment options include endovascular reconstruction and surgical bypass, each with distinct risk profiles.
- Comparative outcome data for high-risk versus lower-risk patients undergoing these procedures are crucial for clinical decision-making.
Purpose of the Study:
- To compare clinical and safety outcomes of endovascular reconstruction versus surgical bypass in patients with TASC II D AIOD.
- To evaluate outcomes based on patient comorbidity risk (higher-risk for endovascular, lower-risk for surgical bypass).
- To assess survival, limb salvage, patency, and symptom improvement in both treatment groups.
Main Methods:
- Retrospective review of 32 consecutive patients with symptomatic TASC II D AIOD treated between 2012 and 2017.
- Patients were divided into two groups: higher comorbidity (underwent endovascular reconstruction, n=19) and lower comorbidity (underwent surgical bypass, n=13).
- Analysis included lesion characteristics, technical approach, survival, limb salvage, patency rates, and clinical symptom changes over a mean follow-up of 2.76 years.
Main Results:
- Endovascular group patients were older and had higher rates of hypertension, coronary artery disease, and renal impairment.
- No significant differences were observed in Rutherford classification between the groups.
- At long-term follow-up, both endovascular reconstruction and surgical bypass demonstrated equivalent rates of survival (89.5% vs 84.6%), limb salvage (100% vs 92.3%), and primary-assisted patency (85% vs 85%). Clinical improvements were also similar.
Conclusions:
- For carefully selected patients, endovascular reconstruction and surgical bypass yield comparable clinical outcomes for TASC II D AIOD at 2.5 years post-procedure.
- Endovascular reconstruction, with its decreased operative risk, is suggested as the preferred technique for high-risk patients with TASC II D AIOD.
- Further research may explore long-term efficacy and cost-effectiveness of both approaches in specific patient populations.
Abstract:
OBJECTIVE. The purpose of this study is to compare the clinical and safety outcomes between two groups of patients with Trans-Atlantic Inter-Society Consensus class D (TASC II D) aortoiliac occlusive disease (AIOD): those with higher-risk comorbidity who underwent endovascular reconstruction and those with lower-risk comorbidity who underwent surgical bypass. MATERIALS AND METHODS. Thirty-two consecutive patients with symptomatic TASC II D AOID who underwent surgical bypass or endovascular reconstruction from 2012 to 2017 were retrospectively reviewed. Lesion characteristics, technical approach, survival, limb salvage, patency, and change in clinical symptoms were analyzed. RESULTS. Nineteen patients with higher comorbidity underwent endovascular reconstruction, whereas 13 patients with lower comorbidity underwent surgical bypass. Patients undergoing endovascular reconstruction had an older median age (67.0 vs 62.0 years; p = 0.007), higher rates of hypertension (94.7% vs 61.5%; p = 0.018) and coronary artery disease (26.3% vs 0%; p = 0.044), and advanced renal impairment (mean [± SD] chronic kidney disease stage, 1.4 ± 1.5 vs 0.7 ± 1.3; p = 0.005). There were no significant differences in Rutherford classification between the groups. During long-term follow-up of 2.76 years, endovascular reconstruction and surgical bypass showed equivalent rates of survival (89.5% vs 84.6%; p = 0.683), limb salvage (100.0% vs 92.3%; p = 0.219), and primary or primary-assisted patency (85% vs 85%; p = 0.98). Groups showed similar clinical improvements in walking distance, rest pain, and tissue loss at 30 days (95% vs 85%; p = 0.158) and at long-term follow-up (74% vs 62%; p = 0.599). CONCLUSION. For properly selected patients, the clinical outcomes of endovascular reconstruction versus surgical bypass for TASC II D AOID may be equivalent at 2.5 years after the procedure. The decreased operative risk associated with endovascular reconstruction suggests that it is the technique of choice for high-risk patients.
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