Factors associated with outcome of endovascular treatment of iliac occlusive disease: a single-center experience / Fatores associados com os desfechos clínicos do tratamento endovascular da doença oclusiva ilíaca: experiência de um único centro

Abstract Background Endovascular treatment (ET) of iliac occlusive disease (IOD) is well established in literature. Use of stents in IOD has achieved long-term limb salvage and patency rates similar to those of open surgery, with lower morbidity and mortality rates. Objectives To report the long-term outcomes, particularly limb salvage and patency rates, of ET for IOD and the factors associated with these outcomes. Methods This retrospective cohort study included patients with IOD who underwent iliac angioplasty (IA), between January 2009 and January 2015. Patients with critical limb ischemia or incapacitating claudication were included. Results In total, 48 IA procedures were performed in 46 patients, with an initial technical success rate of 95.83%. Failure occurred in two patients, who were excluded, leaving 44 patients and 46 IA. The primary patency, secondary patency, limb salvage, and survival rates at 1200 days were 88%, 95.3%, 86.3%, and 69.9%, respectively. Univariate and multivariate Cox regression revealed that the primary patency rate was significantly worse in patients with TASC type C/D than in patients with TASC type A/B (p = 0.044). Analysis of factors associated with major amputation using Cox regression showed that the rate of limb loss was greater in patients with TASC type C/D (p = 0.043). Male gender was associated with reduced survival (p = 0.011). Conclusions TASC type C/D was associated with a higher number of reinterventions and with worse limb loss and primary patency rates. Male gender was associated with a worse survival rate after ET of IOD.

Resumo Contexto O tratamento endovascular da doença oclusiva ilíaca (DOI) é bem estabelecido. O uso de stents nas angioplastias ilíacas (AI) alcançou estimativas de salvamento de membro e perviedade similares às de cirurgias abertas, porém com menor morbimortalidade. Objetivos Demonstrar os desfechos clínicos a longo prazo, principalmente as estimativas de salvamento de membro (ESM) e perviedade, do tratamento endovascular da DOI e os fatores associados. Método Estudo de coorte retrospectiva e consecutiva incluindo pacientes com DOI e isquemia crítica ou claudicação limitante submetidos a AI entre janeiro de 2009 a janeiro de 2015. Resultados Foram realizadas 48 AI em 46 pacientes, com uma taxa de sucesso técnico inicial de 95,83%. Ocorreu falha técnica em dois pacientes, os quais foram excluídos da análise, restando 44 pacientes e 46 AI. As estimativas de perviedade primária, perviedade secundária, ESM e sobrevida aos 1.200 dias foram de 88%, 95,3%, 86,3% e 69,9%, respectivamente. A regressão de Cox univariada e multivariada revelou que a perviedade primária foi pior em pacientes com classificação TASC C/D do que em pacientes TASC A/B (p = 0,044). Quando analisamos os fatores associados à amputação maior, verificou-se que lesões TASC tipo C/D (p = 0,043) apresentaram piores resultados. O sexo masculino foi associado com sobrevida reduzida (p = 0,011). Conclusões Classificação TASC tipo C/D foi associada a um maior número de reintervenções, maior perda de membro e piores estimativas de perviedade primária. O sexo masculino foi associado a uma pior sobrevida.

Aorto-bi-Femoral Bypass for Aorto-Iliac Occlusive Disease: Recent Experience at the National Institute of Cardiovascular Diseases (NICVD).

Background & Objectives: Aorto-bi-femoral bypass is one of the most important surgical strategies in vascular surgical practice. The procedure is employed in surgical revascularization for both stenotic and aneurysmal diseases involving the aorto-iliac segment. The present study was carried out to analyze our recent experiences with this procedure for aorto-iliac occlusive diseases (AIOD) at the National Institute of Cardiovascular Diseases (NICVD). Materials and Methods: Over a period of 3 years (April 2008 to March 2011), a total of 47 patients underwent aorto-bi-femoral or aorto-bisiliac bypass grafting for AIOD using a Y-graft prosthesis. The mean age of the patients was 46.4 years (range 25-75 years). Thirty eight of the patients were male and the remaining 9 were female. A retroperitoneal approach was used in 27 patients. In the remaining 20 patients, the operation was done using a transperitoneal approach. A Gelatin-coated Dacron Y-graft prosthesis was used in 43 (5 of which were silver-coated prosthesis) patients while PTFE (Polytetrafluoroethylene) prosthesis was used in the remaining 4 patients. The operation was carried out under epidural anesthesia with sedation in most cases. Results: The operation was well-tolerated in all patients. There was no intraoperative mortality in this series. Two patients died in the immediate post-operative period- one due to myocardial infarction and the other due to acute renal shut-down leading to renal failure accounting for a mortality rate of 4.3%. Wound infection and lymphorrhoea at the groin incision site were the two main immediate post-operative complications. There was no incidence of graft infection in this series. Twelve patients were available for post-operative follow-up up to 2 years. Out of them, 5 patients returned with occluded grafts 8-23 months after the operation. Three of these patients underwent graft excision with re-do Y-graft bypass. The remaining two were treated with extra-anatomic bypass (Axillobifemoral). Conclusions: Aorto-bi-femoral bypass is an effective surgical strategy for occlusive diseases involving the abdominal aorta and the iliac arteries. The procedure is well-tolerated with a low incidence of early post-procedural complications and graft failure. However, poor adherence of the patients to follow-up remains a significant obstacle for evaluating the long-term outcome of this procedure.

The Relation between Distal Runoff and Clinical Outcome after Aorto-iliac Reconstruction Surgery

PURPOSE: We sought to evaluate the relationship between distal runoff and long-term graft patency in aorto-iliac occlusive disease. METHOD: A retrospective review was performed on 192 patients with aorto-iliac occlusive disease who underwent surgery between September 1995 and November 2005. Patients who underwent percutaneous angioplasty or stent placement were excluded. Preoperative angiograms were scored according to the SVS/ISVS Ad Hoc Committee guidelines. RESULT: The mean duration of follow-up was 50 months. Procedure indications consisted of claudication in 68 patients and critical limb ischemia in 124 patients. Procedures included 176 bypasses (50 aorto-iliac/aorto-femoral, 32 ilio-femoral, 46 axillo-femoral, and 48 femoro-femoral) and 16 endarterectomies with patch angioplasty. Overall 5-year patency rate was 84.1%. Higher primary patency was observed when the occlusion score of the superficial femoral artery (SFA) or deep femoral artery (DFA) was lower than 2 (P<0.05). Cox proportional hazard model showed run-off resistance values to be significant determinants of graft patency (p=0.000, Exp(B)=1.236). The group that underwent profundoplasty had significantly better long-term patency (P=0.009). CONCLUSION: Poor distal runoff score was related to lower primary patency. In patients with aorto-iliac occlusive disease and poor distal outflow, profundoplasty can improve primary patency.