Contemporary Minimally Invasive Surgery for TASC-D Aorto-Iliac Lesions: Analysis of Outcomes and Risk Factors for Primary and Secondary Patency.

BACKGROUND: For complex extensive TASC-II D lesions, the standard of care remains conventional surgery. Nevertheless, guidelines tend to broaden endovascular surgery indications in expert centers for patients at high surgical risk with TASC-II D lesions. Due to the increasing use of endovascular surgery in this setting, we planned to evaluate the patency rate of this approach. METHODS: We conducted a retrospective study in a tertiary center. All patients treated for symptomatic peripheral arterial disease (PAD) with classified D lesions according to the TASC-II classification and requiring management of the aortoiliac bifurcation were retrospectively included between January 1, 2007 and December 31, 2017. The type of surgical approach was classified as a pure percutaneous approach or hybrid surgery. The main objective was to describe long-term patency results. The secondary objectives were to identify risk factors for loss of patency and long-term complications. The primary outcomes were primary patency, primary-assisted patency, and secondary patency at 5 years of follow-up. RESULTS: One hundred and thirty-six patients were included. For the overall population, the primary, primary-assisted, and secondary patency proportions at 5 years were 71.6% (95% confidence interval (CI) 63.2-81%), 82.1% (95% CI 74.9-89.3%), 96.3% (95% CI 92-100%), respectively. For primary patency, there was a significant difference in favor of the covered stent group at 36 months (P < 0.01) and 60 months (P = 0.037). In a multivariate model, only CS and age were associated with a better primary patency (hazard ratio (HR) 0.36, CI 95% [0.15-0.83], P = 0.0193 and an HR 0.07, 95% CI [0.05-0.09], P = 0.005, respectively). The overall rate of perioperative complications was 11%. CONCLUSIONS: We report that endovascular and hybrid surgery are safe and effective in the management of TASC-D complex aortoiliac lesions in mid to long-term follow-up. Short-term and long-term complications were all considered as minor.