Endovascular Iliac Stenting versus Open Aortobifemoral Bypass for Aortoiliac Occlusive Disease: A Retrospective
Ahmed Elmetwally1, Ahmed M Morshed2, Amr Meselhi3
1East Lancashire Hospital, Royal Blackburn Hospital, UK; Faculty of Medicine, Mansoura University, Egypt.
Background:
Aortoiliac occlusive disease (AIOD) causing chronic or critical limb-threatening ischaemia can be treated by open aortobifemoral bypass (ABF) or endovascular reconstruction. Comparative-effectiveness data adjusted for treatment-selection bias remain limited. This multicentre study compared mid-term outcomes of endovascular versus open reconstruction for AIOD.
Methods:
Retrospective, non-randomised cohort study of 171 patients with AIOD (Rutherford 3-6) treated at three centres (UK, Ireland, Egypt) between January 2023 and February 2026. Outcomes were primary patency, freedom from reintervention (FFR), amputation-free survival (AFS), overall survival, and perioperative complications. Cox regression and inverse-probability-of-treatment weighting (IPTW) were used to adjust for confounding.
Results:
125 patients (73.1%) underwent endovascular treatment and 46 (26.9%) open bypass. Endovascular patients were older (66.8 vs 60.8 years, p<0.001) and had a lower burden of TASC C-D disease (53.6% vs 93.5%, p<0.001). Primary patency at 24 months was 62.7% vs 91.8% (log-rank p<0.001; IPTW-adjusted HR 5.67, 95% CI 1.75-18.37). Freedom from reintervention at 24 months was 63.1% vs 93.3% (p<0.001). Amputation-free survival (85.0% vs 87.4%, p=0.992) and overall survival (93.3% vs 90.0%, p=0.335) were comparable between groups. Wound infection was less frequent after endovascular treatment (0.8% vs 10.9%, p=0.006). Major amputation was independently predicted by CLTI presentation (OR 4.0) and age, not treatment group. Progressive infrainguinal disease, rather than failure of proximal revascularisation, accounted for most amputations in both groups.
Conclusion:
Open bypass confers a substantial mid-term patency and reintervention-free survival advantage over endovascular reconstruction for AIOD, most pronounced in TASC D and CLTI subgroups, without a corresponding difference in limb salvage or survival. These findings support risk-stratified rather than uniformly endovascular-first treatment selection, pending confirmation from the ongoing EVOCC randomised trial.
