Unilateral iliac artery occlusive disease: A randomized multicenter trial examining direct revascularization versus crossover bypass

This randomized trial compared the patency of direct unilateral aorto- or iliofemoral prosthetic bypass with that of crossover femorofemoral or iliofemoral bypass in unilateral atheromatous occlusive disease of the iliac artery. Between May 1986 and March 1991, 143 patients were enrolled in this study (74 crossover and 69 direct revascularizations). Cardiovascular risk factors, preoperative symptoms, and atheromatous lesions were similar in both groups. Patients were followed by Duplex scanning with systolic pressure index measurements. Routine digital subtraction arteriograms were obtained postoperatively and separately, when hemodynamic anomalies developed. Mean follow-up was 22 months. One patient with direct revascularization died postoperatively. Primary patency of direct revascularizations was 89.8% at 48 months compared with 52% for crossover bypass. This difference was statistically significant. Secondary patency of direct and crossover revascularization at 48 months was 92.9% and 93.6%, respectively (not significant). Even though crossover bypasses seem attractive because of their technical simplicity and low morbidity, our results suggest that direct revascularizations are preferable in the young patient with no major operative risks, while crossover bypasses remain indicated in patients at risk.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 20–21 1991, Marseille, France.     

Comparison of iliofemoral and femorofemoral crossover bypass in the treatment of unilateral iliac arterial occlusive disease

Between 1981 and 1988, 74 synthetic crossover bypass grafts were inserted for unilateral iliac arterial occlusive disease. In 32 patients the bypass procedure was iliofemoral and in 42 femorofemoral. The cumulative patency rate at a mean of 2.7 years was 79 per cent in both groups. There was no significant difference in either postoperative mortality rate or duration of hospital stay. Iliofemoral bypass may offer significant advantages over the femorofemoral approach. In particular it avoids a groin incision in the donor limb, leaving the common femoral artery intact for subsequent angioplasty or reconstruction should proximal stenotic disease develop in the donor iliac vessel.     

A new approach for the surgical management of unilateral iliac artery occlusive disease: the iliofemoral crossover transposition

Aortobifemoral bypass remains the standard therapy for aortoiliac occlusive disease. Extraanatomic revascularization has been considered as an acceptable alternative and provides reasonable long-term results. Because some of the causes for its failure are related to the prosthetic material used, a technique that uses autologous material and is applicable in patients with unilateral common iliac lesions was developed. Iliofemoral crossover transposition is a femorofemoral bypass procedure in which the external iliac artery is used as a graft. The procedure is easily performed and avoids the use of prosthetic materials, minimizing the risks of their related complications. Because its biologic behavior, including hemodynamic performance, has proven to be excellent, satisfactory long-term results can be anticipated.     

Remote iliac artery endarterectomy: seven-year results of a less invasive technique for iliac artery occlusive disease

OBJECTIVE: Remote endarterectomy of external and common iliac artery occlusions through a single, groin incision under fluoroscopic guidance is a relative unknown surgical procedure. This prospective single center cohort study describes this less invasive endovascular technique with the ring strip cutter and its early complications. The results at midterm follow-up are presented. PATIENTS AND METHODS: From April 1994 to July 2001, 49 remote-endarterectomies of the external or common iliac artery were performed in a retrograde manner from a single, groin incision in 48 patients (30 men, 31 procedures). The median age was 66 years (39 to 82 years). Indications for operation were as follows: severe claudication in 28 (57%), rest pain in 13 (27%), and gangrene in 8 (16%) procedures. Follow-up included clinical evaluation, ankle-brachial index, and duplex scanning at 6 weeks, 3 months, and yearly thereafter. RESULTS: Intraoperative technical success was achieved in 43 (88%) procedures. A retroperitoneal incision was necessary in three patients for an additional arteriotomy in the iliac artery and in three others for a bypass procedure. The mean follow-up was 20 months (2 to 77 months). Three-year cumulative primary patency rate by means of life table analysis was 60.2% +/- 12.0 (SE). During follow-up, percutaneous transluminal balloon angioplasty with and without stenting was performed in six and two patients, respectively, resulting in a 3-year primary-assisted patency rate of 85.7% +/- 9.56. Three-year secondary patency was 94.2% +/- 5.50. CONCLUSIONS: Remote endarterectomy in external and common iliac arterial occlusive disease is a feasible endovascular procedure with a low complication rate. The midterm primary-assisted patency rate is good.     

Femoro-femoral crossover bypass for ruptured iliac artery aneurysm

Atherosclerotic aneurysms of the iliac artery shows a marked tendency to rupture, usually with fatal outcome. A ruptured aneurysm of the left iliac artery in a 76-year-old man was successfully treated by removing the aneurysm and implanting an 8 mm dacron tubular prosthesis as a subcutaneous femoro-femoral crossover graft. The operative technique is described. The advantages of this bypass techniques as the treatment of choice in such cases are discussed.     

术中髂动脉支架结合股动脉旁路术治疗多节段动脉硬化闭塞症

目的 探讨术中髂动脉腔内成形及支架植入结合股-Guo动脉旁路术治疗多节段动脉硬化闭塞症的初步临床经验。方法 采用术中同时行髂动脉腔内成形和支架植入结合股-Guo动脉旁路术治疗多节段动脉硬化闭塞症10例（12条肢体）。结果 术中11条髂动脉行腔内成形和支架植入均获成功,9条肢体行股-Guo动脉人工血管旁路术,3条肢体行股-股-Guo动脉人工血管旁路系列转流术;1条肢体股-Guo动脉旁路术失败,本组患者无重要脏器并发症和手术死亡。平均随访时间6个月（1-12个月,髂动脉腔内支架通畅率100%;3条股-股动脉耻骨上人工血管转流均通畅;而股-Guo动脉人工血管通畅率83.3%;截肢率8.3%。结论 术中髂动脉腔内支架结合股-Guo动脉旁路术是治疗多节段动脉硬化闭塞症的安全、有效方法。     

Treatment of unilateral iliac artery disease by femorofemoral bypass grafting.

Between Jan. 1, 1970 and June 30, 1977, 50 men and 23 women underwent femorofemoral bypass grafting. The average age of the group was 64.7 years. The procedure was performed for disabling claudication in 50 patients and for limb threatening ischemia in 23. Knitted Dacron grafts were used in all but two patients. The operative mortality was 4.1% and the late mortality 21.9%. There were six complications related to the prostheses, three infected grafts and three false aneurysms. Thrombosis of the graft occurred in 15 patients; the graft was successfully revised in 2. The cumulative 5-year patency rate determined by life-table methods was 73.4%. The causes of failure appeared to be well defined and unilateral iliac artery disease. The donor iliac artery, poor runoff through a diseases deep femoral artery on the recipient side and infection of the graft. This study indicates that femoro-femoral bypass has a definite place in the management of patients with unilateral iliac artery disease. The procedure can be performed on selected patients with a low operative mortality and an acceptable patency rate.     

Collagen- versus gelatine-coated Dacron versus stretch PTFE bifurcation grafts for aortoiliac occlusive disease: long-term results of a prospective,randomized multicenter trial

BACKGROUND: In this prospective randomized multicenter trial, knitted gelatine-coated Dacron, knitted collagen-coated Dacron, and stretch polytetrafluoroethylene (PTFE) aortic bifurcation grafts were compared for their long-term results. METHODS: Between 1991 and 1998, 149 patients undergoing elective revascularization for aortoiliac occlusive disease were prospectively randomized at 3 tertiary referral centers of vascular surgery. The patients received either gelatine-coated Dacron (GEL-D) grafts (n = 52), collagen-coated Dacron (COL-D) grafts (n = 49), or stretch PTFE grafts (n = 48). RESULTS: No intraoperative deaths were recorded. The 30-day mortality was 4%. The mean follow-up time was 97 months. Primary patency rates were 77% for GEL-D, 78% for COL-D, and 79% for PTFE at 8 years. The differences were not different (P >.8). Secondary corrected 8-year patency rates were also not significantly different (P >.5): 91% for GEL-D, 96% for COL-Dm and 90% for PTFE. Five Dacron and 1 PTFE grafts were affected by infections. CONCLUSIONS: Bifurcation grafts for revascularization of aortoiliac occlusive disease using these 3 materials were comparable in terms of primary and secondary patency and long-term complication rates.     

Extraperitoneal unilateral iliac artery bypass for chronic lower limb ischaemia

Extraperitoneal unilateral iliac artery bypass was used to treat chronic lower limb ischaemia in 105 patients (110 operations). This represented 20% of all operations for aorto-iliac disease. Unilateral iliac bypass was the preferred primary procedure for 99 operations, and was used to correct complications in one limb of a prior aortic bifurcation graft in the other 11. Ipsilateral femoropopliteal vein grafts were also performed in 45 legs (43%), prior to the iliac bypass in 18, as a synchronous operation in nine, and at a later date in 18 legs. This was a much higher proportion of combined operations than for patients by aortic bifurcation grafts (12%). Only 5 patients later required further proximal surgery, one for a blocked graft and four for contralateral iliac disease. The cumulative patency rate in surviving patients was 91% at 3 years. For the claudicants and for iliofemoral bypass operations, only one graft occluded, within 5 years, and no grafts occluded for operations where the superficial femoral artery was patent. The cumulative patency rates at 3 years were 85% for patients with critical ischaemia, 82% for ilioprofunda bypass operations, and 88% for operations where the superficial femoral artery was occluded. The cumulative foot-salvage rate in surviving patients initially treated for critical ischaemia was 77% at 3 years. The cumulative survival rate was 90% at 3 years. Extraperitoneal unilateral iliac bypass is now preferred as the primary operation for patients with apparent unilateral iliac disease causing severe ischaemia, if balloon dilatation is not appropriate or has failed.     

Progression of occlusive disease following femorofemoral crossover bypass graft

Progression of distal disease is considered the most common cause of femorofemoral artery cross-over bypass graft (FFBPG) failure. Twenty-seven patients with patent grafts (mean 53 months) were evaluated with segmental Doppler and duplex scan arterial studies for evidence of disease progression. In the early postoperative period (compared with preoperative levels), 26 patients (95.3%) showed a significant improvement (>0.1) in the recipient limb ankle-brachial index (ABI) (mean increase of 0.38; SD=0.24) and/or ankle spectral arterial waveform. However, there was a statistically significant decrease (p=0.0001) in the donor limb ABI, and 12 patients (44.4%) had a >0.1 deterioration. On long-term follow-up (compared with preoperative levels) this difference was no longer significant (p=0.49); only seven donor limbs remained with a >0.1 decrease in ABI. The recipient limbs maintained a significant improvement (>0.1) in the ABI compared to preoperative levels (p<0.0001; mean of 0.39; SD=0.16) except for three limbs that had decreased by 0.1. However, eight patients (29.6%) developed an increase in their donor common femoral artery acceleration time >133 msec and/or increased blood flow velocity without a simultaneous significant decrease in their recipient limb ABI. In the latter group the preoperative donor limb common femoral artery acceleration time and ABI and the immediate postoperative change in donor limb ABI were not significantly different (p>0.05) than in the remaining patients. These data suggest that there is a significant but transient decrease in donor limb ABI following FFBPG, that long-term changes in ABIs are symmetric in both limbs, and that inflow surveillance with duplex scanning and acceleration time measurement may allow early detection of hemodynamically significant inflow lesions prior to graft failure. Presented at the Seventeenth Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, Ill., June 7, 1992.     

Hand-assisted laparoscopic aortobifemoral bypass versus open bypass for occlusive disease

BACKGROUND: Aortobifemoral bypass grafting is the treatment of choice for patients with symptomatic aortoiliac occlusive disease. Yet, traditional operative exposure through a midline laparotomy incision carries significant morbidity. The authors compare operative and patient outcomes following hand-assisted laparoscopic aortobifemoral (HALABF) bypass and open aortobifemoral (OABF) bypass. METHODS: An initial series of patients who underwent HALABF bypass grafting (n = 8) were compared with a simultaneous cohort of patients treated with standard open bypass (n = 10). The two groups were similar with respect to age, weight, and sex. Operative parameters, clinical outcomes, and complications were compared. RESULTS: HALABF was successfully performed in all eight cases attempted. Operative times did not differ between the laparoscopic and open groups (234 +/- 42 minutes vs. 206 +/- 43 minutes, P =.99). Mean blood loss values were comparable (562 mL [HALABF] vs. 756 mL [OABF], P =.56). There were no conversions. Time to resumption of oral intake (1.8 vs. 4.7 days, P =.001) and length of stay (3.8 vs. 6.3 days, P =.0004) were significantly shorter in the laparoscopic than in the open group. CONCLUSIONS: HALABF is a safe and technically feasible procedure. When compared with the traditional open operation, this technique may result in shorter hospitalization, more rapid return of bowel function, and earlier return to activity.     

Iliac endarterectomy with crossover ileofemoral bypass grafting for bilateral iliac artery stenosis

The high-risk patient with claudication or impending limb loss secondary to iliac artery occlusive disease presents a difficult management problem. The morbidity and operative mortality rates of an aortoiliac or aortofemoral bypass procedure can be significant in the elderly or high-risk patient with multiple medical problems. An alternative to the axillofemoral bypass graft and other procedures that have been used in this clinical setting is presented. The combination of endarterectomy of the donor iliac vessel and retrorectus crossover bypass graft has been used in five patients, with good results at 6-month to 2-year follow-up. There have been no operative deaths and a retroperitoneal hematoma has been the only complication. One patient required balloon catheter dilatation of a stenotic vessel distal to the bypass graft for relief of recurrent claudication symptoms. This procedure appears to be a safe and effective therapeutic option in the patient considered an unsuitable candidate for aortofemoral bypass grafting because of advanced age or associated medical problems.     

Long-term results of arterial allograft below-knee bypass grafts for limb salvage: a retrospective multicenter study

PURPOSE: Arterial allografts (AAs) have been recently reconsidered in the treatment of critical limb ischemia when vein material is absent, because of the disappointing results with artificial grafts. The aim of this study was to report the results observed in three centers where AAs were used for infrainguinal reconstruction in limb-threatening ischemia. METHODS: Between 1991 and 1997, 165 AA bypass procedures were performed in 148 patients (male, 90) with a mean age of 70 years (range, 20-93 years). Indications for operation were rest pain in 54 cases and tissue loss in 111 cases. Mean resting ankle pressure was 53 mm Hg in 96 patients who did not have diabetes and mean transcutaneous pressure of oxygen was 10 mm Hg in 52 patients who did have diabetes. In 123 cases (75%), there was at least one previous revascularization on the same limb. AAs were obtained from cadaveric donors. The distal anastomosis was to the below-knee popliteal artery in 34 cases, to a tibial artery in 114 cases, and to a pedal artery in 17 cases. RESULTS: At 30 days, the mortality rate was 3.4%; the primary patency rate was 83.3%; the secondary patency rate was 90%; and the limb salvage rate was 98%. During follow-up (mean, 31 months), 65 grafts failed primarily. Causes of primary failure were thought to be progression of the distal disease in 15 cases, myointimal hyperplasia in 16 cases, graft degradation in 10 cases (four dilations, three stenoses, two ruptures, and one dissection), miscellaneous in eight cases, and not known in 16 cases. Primary patency rates at 1, 3, and 5 years were, respectively, 48.7% +/- 4%, 34.9% +/- 6%, and 16.1% +/- 7%. Secondary patency rates at 1, 3, and 5 years were, respectively, 59. 8% +/- 4%, 42.1% +/- 5%, and 25.9% +/- 8%. Limb salvage rates at 1, 3, and 5 years were, respectively, 83.8% +/- 3%, 76.4% +/- 5%, and 74.2 % +/- 8%. CONCLUSION: AA leads to an acceptable limb salvage rate but poor patency rates. A randomized trial that will compare AAs and polytetrafluoroethylene should be undertaken.     

Combined percutaneous transluminal angioplasty and extraanatomic bypass for symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis

We have reviewed our experience with percutaneous transluminal angioplasty of contralateral iliac stenosis and extraanatomic bypass of the occluded iliac artery. Twenty-two men and nine women with a mean age of 65 years (range 46 to 84) presented with symptomatic iliac occlusive disease. Twenty-four (77%) had disabling claudication, four (13%) rest pain, and three (10%) ischemic tissue loss. Six (19%) had undergone previous vascular reconstructive procedures. All had an occluded iliac artery on the symptomatic side and greater than 50% stenosis of the contralateral iliac artery. Percutaneous transluminal angioplasty of the iliac stenosis was done prior to extraanatomic bypass, using polytetrafluoroethylene. There were six late deaths after discharge. The only significant complication was a femoral artery thrombosis which was corrected when the bypass graft was performed. Cumulative primary graft patency was 89% at one year and 81% at three years. The crossover graft occluded in six patients, five within 48 months of surgery, and one after nine years. One of these occluded grafts was salvaged by thrombectomy, for a secondary patency rate of 85% at three years. Two patients required aortobifemoral bypass, one an iliobifemoral bypass and one an ilioprofunda bypass. One patient operated upon for rest pain came to below-knee amputation. Mean resting ankle/brachial systolic pressure index increased significantly on the side of the iliac occlusion from 0.35 ±0.21 to 0.70 ± 0.20 (p < 0.05, paired t test) after the combined procedure. There was no significant difference in the mean resting ankle/brachial systolic pressure index on the contralateral side (0.60 ± 0.22 to 0.65 ± 0.27, ns). Combined iliac percutaneous transluminal angioplasty and femorofemoral bypass is a safe alternative to aortobifemoral bypass for selected patients with aortoiliac arterial occlusive disease. Presented at the Royal Australasian College of Surgeons, General Scientific Meeting, May 1989, Melbourne, Australia.     

Vascular ultrasound surveillance after endovascular intervention for occlusive iliac artery disease

This paper describes vascular ultrasound surveillance after endovascular intervention for occlusive iliac artery disease. There were 105 patients who had 198 procedures in 155 limbs, consisting of 110 balloon dilatations and 88 stentings. The patients were referred to the vascular diagnostic service by several surgeons. All procedures had been considered to be initially technically successful. Colour-Doppler duplex ultrasound studies were performed shortly before and at serial intervals after operation to determine patency rates. Univariate life table analysis showed 69% primary and 96% assisted primary patency at four years. Primary patency rates at four years were significantly worse for stentings (60%) compared to balloon dilatations (71%) (P<0.05). Maximum peak systolic velocities (PSV) were recorded from the treated arteries. Receiver operating characteristics curves showed that PSV >300 cm/s was most accurate for predicting technical failure. Haemodynamic success rates at four years were 72% for PSV >300 cm/s. Results for procedures that were initially successful indicate that long-term primary patency rates for iliac endovascular intervention are acceptable and that assisted primary patency rates are excellent.     

Percutaneous transluminal angioplasty and stenting for iliac artery occlusive disease.

Atherosclerotic iliac artery stenoses respond well to simple balloon angioplasty and have the best results of all of the peripheral vessels. Nonetheless, initial technical failures occur in as many as 20% of patients, most of which can be salvaged with intravascular stenting, as can many of the potential complications; however, even though the initial technical success rates for stenting approach 100%, stenotic recurrences within stents are not infrequent. Whether promising new concepts, such as brachytherapy, gene therapy, and endoluminal grafting, will have a durable impact on the results of iliac angioplasty is yet to be seen. Meanwhile, the excellent results of endoluminal treatment of patients with iliac artery occlusive disease, combined with the relatively low risk for complications compared with surgical revascularization, ensure an enduring role for this modality of treatment and a diminution in the fraction of patients requiring surgery to correct their iliac artery occlusive disease.