Endovascular and Hybrid Interventions for Aortoiliac Occlusive Disease in Patients with Intermittent Claudication

Significant practice variability exists regarding the management of intermittent claudication (IC) across anatomic segments. We sought to answer the question of whether the safety, efficacy, and durability outcomes of an endovascular approach with or without common femoral endarterectomy for complex aortoiliac occlusive disease (AIOD) justify a surgical approach in patients presenting with IC.

A retrospective single-center review of all patients who were treated using an endovascular approach for AIOD with or without common femoral artery endarterectomy (CFE) from 2010 to 2020 was conducted. The review was limited to those with symptoms of IC. Patient- and limb-level preoperative presentations were reviewed. The outcomes were postoperative complications and patency rates in addition to freedom from re-intervention. Subgroup analyses were conducted to compare patients who underwent endovascular and hybrid procedures.

A total of 245 limbs in 180 consecutive patients were analyzed. The mean age was 65 years, and 61% were males. Of 176 patients, 101 (57%) had trans-atlantic inter-society consensus (TASC) class D and 18 (10%) had class C. Eleven limbs (7.4%) had access site complications, 12 (7.9%) had surgical wound complications, and below-the-knee amputation was observed in 2 limbs (0.82%) (2 patients). Two (1.0%) patients had perioperative myocardial infarction (MI), 1 (0.5%) stroke, 1 (0.5%) AKI that progressed to dialysis, and no 30-day mortality. Rutherford's classification was improved during the follow-up period. The 1-, 2-, and 5-year primary patency rates were 94%, 77%, and 58%; primary-assisted patency rates were 98%, 91%, and 79%, respectively; and secondary patency rates were 100% for all follow-up periods. Patients who had concurrent CFE were likely to have hypertension, hyperlipidemia, and anatomically more diffuse disease. No significant differences in patency or reintervention-free survival were observed, though event rates were low in both outcomes and trended toward a protective effect with CFE.

Endovascular management for complex AIOD with or without CFE for IC patients is safe, effective, and durable. These results justify an active, patient-centered approach for this advanced anatomic disease pattern. The morbidity of a hybrid approach in the CFE subset is low, and treatment vessel patency is excellent. The presence of anatomically advanced AIOD is not prohibitive for the treatment of patients with IC; however, careful patient selection is essential.