Iliac Artery Stenting Combined with Ipsilateral Open Femoro-Popliteal Revascularization and Its Effect on Bypass Patency

Abstract

Background: In cases of multilevel obstructive atherosclerotic disease, hybrid procedures of concomitant iliac artery stenting and femoro-popliteal bypass (IS-FPB) may represent a valid approach, but results are still unclear. The aim was to evaluate early and long-term outcomes of concurrent IS-FPB.

Methods: This retrospective study included 75 patients (76 limbs) treated with concomitant IS-FPB between January 2010 and June 2016. All patients were prospectively enrolled in a dedicated database. Long-term patency and limb salvage rates were reported using Kaplan-Meier curves. Clinical presentation, lesion sites and extension, distal runoff, type of stent, and bypass were evaluated for their association with patency using univariate and multivariate analysis.

Results: Mean age was 72.2 ± 9.4 years; the Society for Vascular Surgery comorbidity score was 1.14 ± 0.61. A covered stent (CS) was implanted in 41 (54%) iliac arteries and a bare-metal stent in 35 (46%); a polytetrafluoroethylene graft was used for bypass in 44 limbs (58%) while 32 limbs (42%) had great saphenous vein bypass. Technical success was 99%; the 30-day cumulative surgical complications rate was 6%, mortality 2%, and morbidity 1%. At 42 months, primary patency of the entire ilio-femoral axis was 65.2% (95% confidence interval [CI], 53-86%). This finding was primarily related to femoro-popliteal bypass occlusion (primary patency, 69.5%), rather than iliac stent loss of patency (primary patency, 94.6%). Secondary patency was 77.6% and limb salvage 89.9%. Univariate analysis demonstrated that Rutherford category 5/6 was a negative predictor of FPB patency (P = 0.04), whereas common femoral artery endarterectomy (P = 0.03) and the use of a CS (P = 0.02) were positive predictors. Multivariate analysis finally indicated that the use of CS to treat iliac obstructive disease was an independent predictor of patency (hazard ratio, 0.15; 95% CI, 0.03-0.64; P = 0.01).

Conclusions: Concurrent IS-FPB has acceptable early and long-term results. Even if further studies are needed, the use of a CS for the iliac obstruction seem to provide better outcomes in the hybrid treatment of these cases of multilevel disease.