Open Surgery or Stenting for Aorto-iliac occlusive disease. Which is

best?

Richard GibbsSt Mary’s Regional Vascular Unit

Imperial College NHS TrustLondon UK

Open Bypass Endovascular

• Higher mortality Lower mortality

• High complication rate Low complication rate

• Long hospital stay Short hospital stay

• More durable Less durable

• Young, fit Old, co-morbid

• Gold standard Evolving

Preconceptions

Aortobifemoral Bypass

5 year patency = 82-92%

Aortounifemoral Bypass

5 year patency = 62-78%

Femoro-femoral Cross over

5 year patency = 52-83%

Axillo- bifemoral Bypass

5 year patency = 45-62%

Ileofemoral Bypass

5 year patency = 48-57%

• 850% increase in angioplasty/stenting • 34% increase in the total number of interventions• 15.5% decrease aortofemoral bypass

Survival in patients with PVD

Newman et al. ATVB, 1999

TASC II 2007

Survival in patients with PVD

TASC

• 29 open bypass studies (n=3,733)

• 28 Endo studies (n=1,625)

• TASC C+D

• Open= ABF and endarterectomy

• Endo= angioplasty, balloon/self expanding stents, covered stents

Were the groups comparable?

Endovascular Open p

Claudicants 76% 55% <0.001

CLI 27% 44% <0.001

SFA occlusion 25% 50% <0.001

Renal insufficiency 9% 4% 0.001

Coronary disease 30% 38% 0.005

Pulmonary disease 15% 21% 0.07

Prior vascular intervention

17% 26% 0.126

Open: 2.6%

Endo: 0.7%

Open: 18%

Endo: 13.4%

Complications

Open

• GI 4.9%

• Pulmonary 3.4%

• Stroke 1.1%

• Wound infection 4.6%

• Graft failure 1%

• Cardiac events 4.2%

• Bleeding 1.5%

• Early Thrombosis 3.4%

• Distal Embolization 1.2%

Endovascular

• Stent/vessel occlusion 3.8%

• Pseudoaneurysm 2.6%

• Rupture/perforation 2.4%

• Dissection 3.6%

• Haematoma 4.4%

• Cardiac events 1.7%

• Bleeding 1.9%

• Early Thrombosis 4.9%

• Distal Embolization 4.9%

Durability

Primary patency Open Endovascular p

1 year 95% 86% <0.001

3 years 86% 80% <0.001

5 years 83% 71% <0.001

Secondary patency

1 year 96% 90% <0.002

3 years 92% 87% <0.001

5 years 91% 83% <0.001

‘Endovascular therapies should be considered a first line

treatment option for all patients with aortoiliac disease, especially

those with high risk cardiac comorbidities’

‘In only 2 decades, EVAR was transformed from a procedure exclusively confined to

high risk patients to a primary choice and preferred method for most patients….’

The same paradigm shift from open surgery to complex endovascular

reconstruction is now prevailing for the treatment of aortic occlusion’

TASC D TASC A-C p

Success rate 91.6% 99.3% <0.001

Complications 11.1% 5.2% <0.001

Mortality 0.8% 0.5% 0.463

5 Yr primary patency 77.9% 77.`1% 0.779

5 Yr secondary patency 98.9% 98.1% 0.694

Freedom major amputation 98.5% 99.4% 0.024

Type IV

Peritoneum swept off diaphragm

L crus divided to expose aorta above coeliac

L kidney rotated upwards and to the right

Lateral wall of aorta exposed down to L iliac

Conclusions

• Surgery more durable

• Stenting less invasive

• Age, co-morbidity, lesion extent

• Both modalities needed