PAD in Focus

Aortoiliac Occlusive Disease: Open vs. Endovascular Approach

A number of patient- and disease-specific factors must be considered when deciding the best treatment plan.
Jessica M. Titus

The manifestation of peripheral vascular disease in the aortoiliac segment is common, and thus its management is a frequent part of the day-to-day work for a vascular surgeon or interventionalist. The disease can present in two patterns. Isolated disease in this segment tends to affect younger smokers who most often present with claudication, whereas older patients tend to have more diffuse disease with multilevel involvement and may present with critical limb ischemia.

Historically, the gold standard for treatment of aortoiliac occlusive disease has been an aortobifemoral bypass. The operation provides excellent long-term patency rates of 82% to 92% at 5 years and 72% to 87% at 10 years. However, this comes with risk for potentially significant complications (Table). In the past, the only alternative for patients who could not tolerate an aortobifemoral bypass would be an extra-anatomic bypass involving either an axillary-femoral with or without a femoral-femoral bypass depending upon the disease pattern. The long-term patency rates of these are substantially less than an aortobifemoral bypass, with reported primary patency rates at 5 years of 35% to 70% for an axillary-femoral bypass and 60% to 70% for a femoral-femoral bypass.

Endovascular approaches were born out of the desire for less invasiveness and began with the first iliac angioplasty in 1964 by Charles T. Dotter, MD. It progressed over a short time to being a viable alternative therapy for those who could not tolerate the open approach. However, with advancements in technique, interventionalist skills, technology and stent selection, endovascular outcomes are significantly improving to the point of rivaling open therapy in many series. The Dutch iliac stent trial in 1998 solidified stenting as a first-line therapy option.

Patient Selection

Given all of the options, the question has become: Which approach is best for which patient? To attempt to answer this, the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were published in 2000. However, these rapidly became outdated and TASC II was published shortly thereafter in 2007 (Figure). Gen. Douglas MacArthur is quoted as saying, “Rules are mostly made to be broken and are too often for the lazy to hide behind.” He would be proud of the vascular world, as several groups rapidly began publishing good, durable outcomes even in TASC C and D lesions. Wading through the literature to try to decipher the best therapy is somewhat difficult. There do not appear to be many absolute truths when it comes to choosing between interventions, but a couple of themes have become evident and can help one to consider different points for each individual patient they encounter. Most papers demonstrate superior patency rates long term with open surgery, but at the cost of more significant and more frequent complications. Along with this, however, endovascular means of treating aortoiliac occlusive disease necessitates more frequent reinterventions to maintain patency. With this in mind, there are also several factors to consider, both patient-specific and disease-specific, before recommending a treatment plan.

Patient-specific factors include patient comorbidities, most notably cardiopulmonary disease, which may take the consideration of open surgery off the table completely. In patients who are borderline, full assessment of their cardiopulmonary risk for the procedure should be undertaken. One paper showed an improvement in endovascular outcomes in patients with known CVD; this was thought to be a surrogate of better medical management with risk factor modification, highlighting the need for this to be addressed in all patients regardless of approach.

A patient’s age should also be considered. Concern about 10-year patency may not be legitimate for some patients who are of advanced age or who have other comorbidities, such as cancer, which would be expected to take their lives earlier. On the contrary, patients on the younger end of the spectrum may be best served with open therapy to avoid the multiple reinterventions often required with an endovascular approach. Sex-specific factors may play some role, with most series showing poorer endovascular outcomes in women.

Disease-related Factors

Disease-specific factors include that the severity of disease must be considered in patients with long-segment occlusions, and patients who present with CLI generally show better outcomes with an open approach. The external iliac artery involvement also seems to be an important factor to consider. Multiple series have shown decreased patency with an endovascular approach, specifically attributable to involvement of the external iliac artery. A disease pattern including the common femoral artery has been shown to be treated well with a hybrid approach; however, with significant obstructive disease beyond the femoral arteries, most papers suggest an improved patency long term with open bypass to treat the inflow disease.

Multidisciplinary Planning Essential

Ultimately, multiple approaches may be reasonable in different patients, and one suggestion to help guide best therapy in truly complex patients is to involve colleagues in planning. Multidisciplinary discussion involving vascular surgery, vascular interventionalists, cardiologists and primary care physicians will likely be the best way to truly risk stratify and define the best therapy for the individual patient.

Disclosure: Titus reports no relevant financial disclosures.

Jessica M. Titus

The manifestation of peripheral vascular disease in the aortoiliac segment is common, and thus its management is a frequent part of the day-to-day work for a vascular surgeon or interventionalist. The disease can present in two patterns. Isolated disease in this segment tends to affect younger smokers who most often present with claudication, whereas older patients tend to have more diffuse disease with multilevel involvement and may present with critical limb ischemia.

Historically, the gold standard for treatment of aortoiliac occlusive disease has been an aortobifemoral bypass. The operation provides excellent long-term patency rates of 82% to 92% at 5 years and 72% to 87% at 10 years. However, this comes with risk for potentially significant complications (Table). In the past, the only alternative for patients who could not tolerate an aortobifemoral bypass would be an extra-anatomic bypass involving either an axillary-femoral with or without a femoral-femoral bypass depending upon the disease pattern. The long-term patency rates of these are substantially less than an aortobifemoral bypass, with reported primary patency rates at 5 years of 35% to 70% for an axillary-femoral bypass and 60% to 70% for a femoral-femoral bypass.

Endovascular approaches were born out of the desire for less invasiveness and began with the first iliac angioplasty in 1964 by Charles T. Dotter, MD. It progressed over a short time to being a viable alternative therapy for those who could not tolerate the open approach. However, with advancements in technique, interventionalist skills, technology and stent selection, endovascular outcomes are significantly improving to the point of rivaling open therapy in many series. The Dutch iliac stent trial in 1998 solidified stenting as a first-line therapy option.

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Patient Selection

Given all of the options, the question has become: Which approach is best for which patient? To attempt to answer this, the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were published in 2000. However, these rapidly became outdated and TASC II was published shortly thereafter in 2007 (Figure). Gen. Douglas MacArthur is quoted as saying, “Rules are mostly made to be broken and are too often for the lazy to hide behind.” He would be proud of the vascular world, as several groups rapidly began publishing good, durable outcomes even in TASC C and D lesions. Wading through the literature to try to decipher the best therapy is somewhat difficult. There do not appear to be many absolute truths when it comes to choosing between interventions, but a couple of themes have become evident and can help one to consider different points for each individual patient they encounter. Most papers demonstrate superior patency rates long term with open surgery, but at the cost of more significant and more frequent complications. Along with this, however, endovascular means of treating aortoiliac occlusive disease necessitates more frequent reinterventions to maintain patency. With this in mind, there are also several factors to consider, both patient-specific and disease-specific, before recommending a treatment plan.

Patient-specific factors include patient comorbidities, most notably cardiopulmonary disease, which may take the consideration of open surgery off the table completely. In patients who are borderline, full assessment of their cardiopulmonary risk for the procedure should be undertaken. One paper showed an improvement in endovascular outcomes in patients with known CVD; this was thought to be a surrogate of better medical management with risk factor modification, highlighting the need for this to be addressed in all patients regardless of approach.

A patient’s age should also be considered. Concern about 10-year patency may not be legitimate for some patients who are of advanced age or who have other comorbidities, such as cancer, which would be expected to take their lives earlier. On the contrary, patients on the younger end of the spectrum may be best served with open therapy to avoid the multiple reinterventions often required with an endovascular approach. Sex-specific factors may play some role, with most series showing poorer endovascular outcomes in women.

Disease-related Factors

Disease-specific factors include that the severity of disease must be considered in patients with long-segment occlusions, and patients who present with CLI generally show better outcomes with an open approach. The external iliac artery involvement also seems to be an important factor to consider. Multiple series have shown decreased patency with an endovascular approach, specifically attributable to involvement of the external iliac artery. A disease pattern including the common femoral artery has been shown to be treated well with a hybrid approach; however, with significant obstructive disease beyond the femoral arteries, most papers suggest an improved patency long term with open bypass to treat the inflow disease.

Multidisciplinary Planning Essential

Ultimately, multiple approaches may be reasonable in different patients, and one suggestion to help guide best therapy in truly complex patients is to involve colleagues in planning. Multidisciplinary discussion involving vascular surgery, vascular interventionalists, cardiologists and primary care physicians will likely be the best way to truly risk stratify and define the best therapy for the individual patient.

Disclosure: Titus reports no relevant financial disclosures.