Iliac artery stenting combined with open femoral endarterectomy is as effective as open surgical reconstruction for severe iliac and common femoral occlusive disease

Abstract

Purpose: To compare outcomes of hybrid repair (HR) combining iliac artery stenting and open common femoral endarterectomy (CFE) with open aortoiliac and femoral reconstruction (OR) in patients with extensive iliac and common femoral occlusive disease (IFOD).

Methods: Between 1998 and 2008, 92 patients (164 limbs) underwent OR and 70 (84 limbs) underwent HR. All patients underwent concomitant CFE. Thirty-day mortality and morbidity, long-term patency, procedurally related limb salvage, and overall survival were analyzed after stratification by iliac TransAtlantic InterSociety Consensus (TASC) classification into TASC A/B and TASC C/D.

Results: HR patients were older for both TASC groups (A/B, P = .02; C/D, P = .01) and had higher Society for Vascular Surgery (SVS) cardiac comorbidity scores (A/B, P = .01; C/D, P < .001) compared with OR. Technical success was ≥99% in both groups. An increase in the ankle-brachial index after the procedure was significantly higher in OR patients (0.49 ± 0.28) with TASC A/B lesions than HR (0.22 ± 0.18, P = .031). Hospital and intensive care unit (ICU) lengths of stay were 3.9 days for HR patients in TASC C/D vs 9.4 days for OR patients (P = .005). Comparing HR and OR, 30-day morbidity (3% vs 5%, P = .55) and mortality (1.1% vs 1.4%, P = .85) were equivalent. Primary patency of HR vs OR at 3 years was similar (91% vs 97%, P = .29) and was maintained after stratification by TASC A/B (89% vs 100%, P = .38) and TASC C/D (95% vs 97%, P = .54). Multivariate analysis for patency indicated that major tissue loss (Rutherford class 6) at presentation in the HR group was predictive of decreased long-term patency (P = .02). Limb salvage at 3 years was 100% in both groups. Overall survival was 74% for OR vs 40% for HR (P = .007).

Conclusion: IFOD can be treated using HR with similar early and long-term efficacy vs OR. HR patients with TASC C/D lesions experienced a shorter ICU and hospital stay than OR patients. HR should be considered for all patients with IFOD regardless the severity of TASC classification, particularly in those with high surgical risk. When deciding between HR and OR, one must consider that major tissue loss at presentation is a negative predictor of long-term patency in patients undergoing HR.