Hybrid-based iliofemoral endarterectomy for severe and complete iliofemoral occlusive disease

Abstract

Objective: Primary endovascular approaches are now the dominant modality for the treatment of iliac occlusive disease. However, stenting of the external iliac artery is plagued with high in-stent restenosis rates. This hybrid approach with fluoroscopic, retrograde iliofemoral endarterectomy combined with stenting was previously demonstrated to be both a safe and effective alternative to bypass and primary stenting alone for TransAtlantic Inter-Society Consensus (TASC) II C and D lesions. In this study, early outcomes and hemodynamic improvements of this hybrid approach are evaluated with an expanded patient population.

Methods: This was a single-institution, retrospective review of all hybrid-based retrograde iliofemoral endarterectomies from the common femoral artery extending to the proximal external iliac artery from January 1, 2010, to November 15, 2017. Data were collected from the electronic medical record and analyzed using standard quantitative statistical techniques. All preprocedure and postprocedure imaging was independently reviewed by two vascular surgeons. Variables included patient demographics, degree of ischemia, and stent characteristics. The primary outcomes were mortality and freedom from amputation, with secondary outcomes including changes in the ankle-brachial index and toe pressure.

Results: The procedure was performed on 63 limbs in 51 total patients. In 33 limbs, the indication was critical limb ischemia (tissue loss/gangrene = 17, rest pain = 16) and 30 for lifestyle-limiting claudication. The cohort consisted of 84% TASC D and 16% TASC C. External iliac stenting was required in 68% (modal diameter, 10 mm) and ipsilateral common iliac stenting was completed in 75% (modal diameter, 9 mm). The ankle-brachial index significantly improved from 0.42 ± 0.25 to 0.73 ± 0.27 (P < .001) as did toe pressure from 29 ± 27 mm Hg to 59 ± 34 mm Hg (P < .001). Thirteen limbs ultimately required an infrainguinal procedure. One patient experienced an intraoperative iliac perforation that resolved with stenting. One death occurred within 90 days. Ninety-five percent of patients remained free from amputation.

Conclusions: Extensive hybrid-based, retrograde iliofemoral endarterectomy with stenting is a safe and efficacious approach to severe iliac arterial occlusive disease, with excellent early outcomes. This series promulgates the hypothesis that extensive endarterectomy with selective iliac stenting yields superior results to external iliac stenting alone. Given the superb hemodynamic improvements in a larger patient population, this hybrid-based, extensive iliofemoral endarterectomy should be recommended as a minimally invasive, first-line treatment for severe iliac occlusive disease.

Keywords: Endarterectomy; Endovascular; Hybrid; Iliac artery; TASC D.