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 Table of Contents  
Year : 2018  |  Volume : 16  |  Issue : 3  |  Page : 309-313

The outcome of treatment of Trans-Atlantic Inter-Society Consensus D aortoiliac disease

1 Department of Vascular Surgery, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
2 Radio-Diagnosis, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt

Date of Submission30-Oct-2018
Date of Acceptance04-Feb-2019
Date of Web Publication15-Apr-2019

Correspondence Address:
Maisa A Abdel Wahab
Nasr City, Cairo 11651
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AZMJ.AZMJ_119_18

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Objective The long-term durability of the open bypass is better than that of endovascular treatment (EVT) for Trans-Atlantic Inter-Society Consensus (TASC) D aortoiliac lesions, but many recently developed devices and a variety of access options have increased the success rates of EVT, with less operative mortality and complication rates. In this study, we aimed to compare the technical success rates, primary patency rate, clinical outcomes, and complication for TASC D aortoiliac lesions treated by endovascular and surgical procedures.
Patients and methods Data from 89 patients with chronic iliac artery stenosis and/or occlusion who were treated with endovascular or surgical treatment were retrospectively reviewed in the period between January 2003 and December 2017.
Results The procedure time was longer for the surgical group than for the EVT group. The total complication rate was higher in the surgical group than in the EVT group. The mortality rate associated higher with the surgical group. There was no statistically significant difference between the groups regarding 2-year primary patency rates.
Conclusion This study revealed that patients with severe aortoiliac occlusive disease (TASC D) can be treated with EVT or surgically with satisfactory results, with better technical success in the surgical group than in the EVT group. Furthermore, the 2-year patency rate for both groups was acceptable.

Keywords: endovascular treatment, iliac artery, outcomes, outcomes, peripheral arterial disease, surgical repair, Trans-Atlantic Inter-Society Consensus

How to cite this article:
Abdel Wahab MA, Saleh OI. The outcome of treatment of Trans-Atlantic Inter-Society Consensus D aortoiliac disease. Al-Azhar Assiut Med J 2018;16:309-13

How to cite this URL:
Abdel Wahab MA, Saleh OI. The outcome of treatment of Trans-Atlantic Inter-Society Consensus D aortoiliac disease. Al-Azhar Assiut Med J [serial online] 2018 [cited 2020 Jul 15];16:309-13. Available from: http://www.azmj.eg.net/text.asp?2018/16/3/309/255852

  Introduction Top

Aortoiliac occlusion is an advanced manifestation of the atherosclerotic vascular disease. Patients with this complicated and frequently multilevel disease can present with life-limiting claudication to limb-threatening ischemia. The goal of treatment involves re-establishment of inflow to the lower extremities and pelvis [1].

The most recent Trans-Atlantic Inter-Society Consensus (TASC) II guidelines emphasize that open surgical reconstruction (aortobifemoral bypass grafting) is the gold standard of treatment of TASC D lesions involving longer and multisegment stenosis and occlusions. The operative morbidity and mortality of this major abdominal operation in high-risk patients is highly significant, resulting in increased interest and use of less-invasive approaches to achieve a similar therapeutic end point [2].

Percutaneous transluminal angioplasty and stenting have offered more alternatives to open surgery and offer successful techniques to patients who may have been considered at an unacceptably high risk for conventional open surgical repairs and offer the advantages of less morbidity, faster recovery, and shorter hospital stays [3].

An endovascular recanalization and stenting of chronic iliac occlusions can be performed under local anesthesia and as an outpatient procedure, which makes it an attractive alternative for patients who are at high risk for open aortic surgery or general anesthesia, or both [4].

Invasive, digital subtraction angiography has been the gold standard for evaluation of lower extremity atherosclerosis. Characterization of peripheral arterial disease and follow-up of stenting can be also performed with noninvasive angiography using computed tomography angiography (CTA) or MR angiography as well as with duplex ultrasonography [5].

CTA image interpretation is aided by the use of advanced postprocessing techniques. Volume-rendered three-dimensional reconstruction of the arterial tree provides a global overview of the rapid identification of pathology. Maximum intensity projection images provide similar views to traditional angiography and are useful for qualitatively assessing the degree of stenosis [6].

  Patients and methods Top

The research was performed according to the World Medical Association Declaration of Helsinki, and informed consent was obtained from research patients.

From January 2003 till December 2017, data from 89 patients with chronic iliac artery stenosis and/or occlusion with or without aortic stenosis (TASC D) who treated with endovascular or surgical procedures were retrospectively reviewed.

Medical records and angiography images were reviewed for demographic data, anatomic lesion, complications, and other outcomes.

Patients with an abdominal aortic aneurysm, restenotic lesions, or patients with acute limb ischemia were excluded.

All patients underwent preoperative ankle-brachial indexes (ABI) and duplex ultrasonography examinations to determine the hemodynamic data.

All patients had radiological imaging, including digital subtraction angiography, CTA, or MR angiography.

All patients were treated for endovascular treatment (EVT) or surgery if they reported disabling claudication, had failed with medical therapy, or had rest pain or tissue loss.

Open repair

Direct aortoiliac bypass operations were performed in an operating room under general anesthesia via a transperitoneal approach and unilateral bypass procedures via a retroperitoneal approach under epidural anesthesia. Y-shaped dacron graft for bilateral aortoiliac and polytetrafluoroethelene (PTFE) graft for unilateral iliac lesion were used for all the aortoiliac surgical reconstructions, and clopidogrel (75 mg/day) was prescribed for 6 months after the operation.

Endovascular treatment

The endovascular procedures were performed in the angiography suite. Under local anesthesia, an ipsilateral or a contralateral approach with a 6-Fr introducer was used depending on the clinical situation. Perioperative anticoagulation with heparin 5000 IU was performed.

Balloon-expandable stents (EV3 and Medtronic, Ireland) were used preferentially for more focal lesions and severely calcified lesions. Self-expandable stents (EV3, Medtronic/Invatec) were usually placed for a diseased long segment or when the contralateral approach for stenting was used, as in [Figure 1] and [Figure 2] (a for before and b for the after). After stent implantation, aspirin (100 mg/day) and clopidogrel (75 mg/day) were prescribed for 6 months, and after 6 months, aspirin (100 mg/day) was recommended for life-long use.
Figure 1 (a) A case of total occlusion of right CIA, EIA, and ulcerated stenotic lesion in left CIA. (b) Kissing stents in both CIAS and right EIA angioplasty. CIA, common iliac artery; CIAS, common iliac artery stenting; EIA, external iliac artery; IAS, iliac artery stenting.

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Figure 2 (a) Total occlusion of left CIA. (b) Kissing stents in both CIAS and left EIA stenting.

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The treated aortoiliac lesions were assessed by duplex ultrasonography examination, and ABI was measured at 1, 3, 6, and 12 months postoperatively and annually thereafter if present. Angiography was performed when there were recurrent symptoms, a decrease of 0.15 in ABI, and/or an increase of more than 300 cm/s in the peak systolic velocity.

Technical success was defined as evident by good refilling in completion angiography, no residual hemodynamically significant stenosis (<30%), and return of distal pulse or elevated postprocedural ABI, and patency of the graft.

The complications and mortality rates within 30 days were determined.

The following measures were taken:
  1. Anatomical site, length, diameter, kinking, the presence of thrombus, and calcification of the aortoiliac arteries.
  2. Occlusion or stenosis (single or multiple, concentric, or eccentric).
  3. Runoff status distal to the affected segment or presence of another occlusive arterial disease as superficial femoral artery lesions.
  4. New lesions detected at follow-up.

Statistical analysis

The statistical analysis was carried out with the software IBM SPSS Statistics 20 (IBM SPSS Inc., Chicago, Illinois, USA). The quantitative data are presented as the mean and the SD or as the mean SE. For testing the statistical hypothesis, the significance level of 0.05 was selected. For comparing the means of two groups, the independent samples t test was used. For testing the statistical hypothesis about the independence of two variables, the χ2 test was used. All the analyses were performed according to the principle of intention to treat. A primary patency and assisted primary patency were determined with the Kaplan–Meier method, and the log-rank test was used to compare the results between the stent and surgery groups.

  Results Top

In total, 32 patients underwent iliac artery stenting IAS implantations (37 stents) and 57 patients underwent aortoiliac surgical reconstruction. The patients undergoing IAS had a mean age of 57.9±9.9 years, and the patients undergoing aortoiliac bypass were younger (53.2±9.5 years; P=0.0300). Other demographic and clinical characteristics were described in [Table 1].
Table 1 Demographic and clinical data

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Technical success was achieved in 31 (96.8%) cases of 32 cases in the endovascular group; failure to cross the lesions occurred in one case owing to the presence of heavily calcified external iliac artery, and this case was converted to open surgery in the form of aortobifemoral bypass. Technical success for the open surgical group was 100%, as in [Table 2].
Table 2 Lesion morphology and procedure-related factors and technical success

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The overall complication rate (first 30 days) in the endovascular group was 12.5% (4/32) in the form of stent occlusion, whereas in the open repair group was 17.5% (10/57), where three cases had myocardial infarction and died, five cases had graft thrombosis, and wound infection was found in two cases, as in [Table 3].
Table 3 Complications and mortality in first 30 days

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Clinical success was defined as relief of rest pain or improvement of healing of tissue loss and limb salvage.

We found that 28 (87.5%) cases in the endovascular group had relief of rest pain and showed healing of the ulcer. Four (12.5%) cases developed recurrent symptoms.

On the contrary, the open surgical group had 49 (85.9%) cases with clinical success and eight (14.1%) cases had failure, where three cases had died and five cases had gangrene forefoot.

At 1, 3, and 6 months of follow-up, the primary patency rates were the same in EVT group (87.5%), whereas in surgical group were 85.9, 84.2, and 84.2%, respectively.

At 12 months of follow-up, two cases of the endovascular group had recurrent symptoms or worsening of their limb ischemia. Investigations revealed the presence of stent occlusion. One case has occluded iliofemoral bypass in the surgical group.

The 2-year primary patency rates were 81.2% for EVT lesions and 80.7% for the surgical group; however, there was no statistically significant difference between the groups considering the primary patency rates, as in [Table 4].
Table 4 Primary patency during follow-up period among patients (N=89)

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  Discussion Top

To compare endovascular with open repair, many studies were done as the United Kingdom Endovascular Repair 1 trial. In this trial, from 1999 through 2004 at 37 hospitals in the United Kingdom, 1252 patients with the aortoiliac block were randomly assigned to undergo either endovascular or open repair; 626 patients were assigned to each group. Patients were followed for rates of death, graft-related complications, and reinterventions.

In this large, randomized trial, endovascular repair was associated with a significantly lower operative mortality than open surgical repair [7].

Indes et al. [8] found that in a systematic review and meta-analysis designed to examine the clinical outcomes of endovascular and open bypass treatment for AIOD that EVT was associated with shorter hospital stays, lower complication rates, and reduced 30-day mortality, whereas open bypass was associated with higher primary and secondary patency rates at 1, 3, and 5 years [8].

Rimantas et al. [9] reported that iliac artery percutaneous transluminal angioplasty and stent placement are nowadays considered as alternative therapeutic options to open surgery for patients having a symptomatic aortoiliac occlusive disease. In their study, the primary patency rates after IAS at 1 and 2 years were 83.0 and 79.9%, respectively. Their results are similar to those determined by Sixt et al. and Kashyap et al. [9]: 86 and 82%, respectively. However, Soga et al. [9] reported the primary iliac stent patency at 1 and 3 years to be 92.5 and 82.6%, respectively. In the recent large-scale prospective multicenter trial by Rimantas et al. [9], the authors revealed the primary stent patency rates at 12 months was 93.1%.

This study demonstrated a 100% technical success rate and an 80.7% primary patency rate at 2 years for surgical repair and a 96.8% technical success rate and 81.2% primary patency at 2 years for EVT. Moreover, EVT has shorter hospital stay (4 days), lower complication rate (12.5%) with no mortality rate recorded, whereas open repair has a long period of hospital stay (14 days), high complication rate (17.5%), and high mortality rate (5.2%).

  Conclusion Top

This study revealed that patients with severe aortoiliac occlusive disease (TASC D) can be treated with EVT or surgically with satisfactory results, with better technical success in the surgical group than in the EVT group. Furthermore, the 2-year patency rate for both groups was acceptable.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Moon KL, Yu Z, Hiroshi S, Sung M. Diabetic complications and PAD. 8th Asian PAD Workshop. Ann Vasc Dis 2017; 10:449–458.  Back to cited text no. 1
Jonathan L, Palma S. Endovascular management of TransAtlantic Inter-Society Consensus D iliac artery occlusion secondary to radiation arteritis. J Vasc Surg Cases Innov Tech 2018; 4:109–111.  Back to cited text no. 2
Khanjan HN. Aorto-iliac occlusive disease (AIOD) background. Vasc Surg 2017; 20:431–439.  Back to cited text no. 3
Aggarwal V, Waldo SW, Armstrong EJ. Endovascular revascularization for aortoiliac atherosclerotic disease. Vasc Health Risk Manag 2016; 46:119–121.  Back to cited text no. 4
Mariana C, Gabriel O. Non-invasive imaging techniques in lower extremity artery disease. peripheral arterial disease. Eur Soc Cardiol 2018; 16:5.  Back to cited text no. 5
Dappa E, Higashigaito K, Fornaro J, Leschka S, Wildermuth S, Alkadhi H. Cinematic rendering − an alternative to volume for 3D computed tomography imaging. Insights Imaging 2016; 7:849–856.  Back to cited text no. 6
Sachwani GR, Hans SS, Khoury MD. Results of iliac stenting and aortofemoral grafting for iliac artery occlusions. J Vasc Surg 2013; 57:1030–1037.  Back to cited text no. 7
Indes JE, Pfaff MJ, Farrokhyar F. Clinical outcomes of 5358 patients undergoing direct open bypass or endovascular treatment for aortoiliac occlusive disease: a systematic review and meta-analysis. J EndovascTher 2013; 20:443–455.  Back to cited text no. 8
Rimantas B, Zana K, Aleksandras A, Rytis SK, Donatas I, Sarunas K. Comparison of results of endovascular stenting and bypass grafting for TransAtlantic Inter-Society (TASC II) type B, C and D iliac occlusive disease. Arch Med Sci 2016; 12:353–359.  Back to cited text no. 9


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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