Eversion Endarterectomy of the External Iliac Artery in Treating Chronic Limb-Threatening Ischemia in TASC II C and D Iliofemoral Occlusive Disease

BACKGROUND: Endovascular treatment of iliofemoral occlusive disease is a challenging approach, especially for TransAtlantic Inter-Society C and D lesions. Therefore, the revascularization procedure in such situations is preferably performed by bypass graft surgery with synthetic materials. The purpose of this study is to report the feasibility and mid-term results of eversion endarterectomy of the external iliac artery (EEEIA), as an alternative autologous option. METHODS: Retrospective study with 18 EEEIA performed between September 2015 and February 2020, exclusively for chronic limb-threatening ischemia treatment in patients with increased risk of postoperative surgical infection and inadvisable for endovascular treatment. Demographic, clinical variables and outcomes were collected from a prospective database. The main end points are: amputation-free survival (AFS) and 30-day mortality. Secondary end points include: primary patency (PP), cumulative patency (CP), overall survival (OS), and postoperative surgical complication. Kaplan­Meier analysis was used to estimate cumulative time of outcomes. RESULTS: The mean age was 64.8 ± 8.3 years, with predominance of men. The median follow-up period was 1012 days, 95% confidence interval [119, 1365] days. Most had Rutherford 5 (n = 13, 72.2%) and mean ankle brachial index was 0.38 ± 0.22. The PP, CP, AFS, and OS in 730 days were 81%, 92%, 80%, and 88%, respectively. There was no 30-day mortality or postoperative surgical infection. CONCLUSIONS: Iliofemoral reconstruction through EEEIA is an effective surgical procedure with good patency rates, AFS and OS. In addition, it can be considered an useful and safe option, especially in cases in which a prosthesis should be avoided.

Eversion Endarterectomy of the External Iliac Artery in Treating Chronic Limb-Threatening Ischemia in TASC II C and D Iliofemoral Occlusive Disease.

BACKGROUND: Endovascular treatment of iliofemoral occlusive disease is a challenging approach, especially for TransAtlantic Inter-Society C and D lesions. Therefore, the revascularization procedure in such situations is preferably performed by bypass graft surgery with synthetic materials. The purpose of this study is to report the feasibility and mid-term results of eversion endarterectomy of the external iliac artery (EEEIA), as an alternative autologous option. METHODS: Retrospective study with 18 EEEIA performed between September 2015 and February 2020, exclusively for chronic limb-threatening ischemia treatment in patients with increased risk of postoperative surgical infection and inadvisable for endovascular treatment. Demographic, clinical variables and outcomes were collected from a prospective database. The main end points are: amputation-free survival (AFS) and 30-day mortality. Secondary end points include: primary patency (PP), cumulative patency (CP), overall survival (OS), and postoperative surgical complication. Kaplan-Meier analysis was used to estimate cumulative time of outcomes. RESULTS: The mean age was 64.8 ± 8.3 years, with predominance of men. The median follow-up period was 1012 days, 95% confidence interval [119, 1365] days. Most had Rutherford 5 (n = 13, 72.2%) and mean ankle brachial index was 0.38 ± 0.22. The PP, CP, AFS, and OS in 730 days were 81%, 92%, 80%, and 88%, respectively. There was no 30-day mortality or postoperative surgical infection. CONCLUSIONS: Iliofemoral reconstruction through EEEIA is an effective surgical procedure with good patency rates, AFS and OS. In addition, it can be considered an useful and safe option, especially in cases in which a prosthesis should be avoided.

Alternative iliofemoral revascularization in extensive aortoiliac occlusive disease.

Over recent decades, there has been a considerable increase in use of endovascular methods to treat aortoiliac occlusive disease. It has been demonstrated that this approach offers many benefits, primarily for non-complex arterial lesions of the iliac axis, but difficulties persist with achieving adequate results over the medium and long term when treating extensive occlusive disease. Arterial bypasses to alternative vicarious arteries of the femoral-genicular complex for limb salvage are well known in the literature describing cases that are not favorable for conventional or endovascular surgery. We describe the case of a patient with extensive aortoiliac occlusive disease treated with an arterial bypass in the iliofemoral territory, using an alternative autologous substitute and the descending lateral femoral artery as recipient artery. Alternative bypasses and substitutes that are normally reserved for exceptional cases can and should be part of the vascular therapeutic arsenal and have a contribution to make in cases in which endovascular surgery does not yet enable us to achieve good results.

Alternative iliofemoral revascularization in extensive aortoiliac occlusive disease / Revascularização ilíaco-femoral alternativa em doença oclusiva aortoilíaca extensa

ABSTRACT Over recent decades, there has been a considerable increase in use of endovascular methods to treat aortoiliac occlusive disease. It has been demonstrated that this approach offers many benefits, primarily for non-complex arterial lesions of the iliac axis, but difficulties persist with achieving adequate results over the medium and long term when treating extensive occlusive disease. Arterial bypasses to alternative vicarious arteries of the femoral-genicular complex for limb salvage are well known in the literature describing cases that are not favorable for conventional or endovascular surgery. We describe the case of a patient with extensive aortoiliac occlusive disease treated with an arterial bypass in the iliofemoral territory, using an alternative autologous substitute and the descending lateral femoral artery as recipient artery. Alternative bypasses and substitutes that are normally reserved for exceptional cases can and should be part of the vascular therapeutic arsenal and have a contribution to make in cases in which endovascular surgery does not yet enable us to achieve good results.

RESUMO Nas últimas décadas, observou-se o aumento expressivo do tratamento endovascular para a doença oclusiva aortoilíaca. Muitos benefícios foram demonstrados, principalmente nas lesões arteriais não complexas do eixo ilíaco; porém, ainda existe dificuldade na obtenção de resultados adequados a médio e longo prazo quando falamos de doenças oclusivas extensas. As derivações arteriais para artérias vicariantes alternativas do complexo femoro-genicular para salvamento de membro são bem conhecidas na literatura em casos desfavoráveis para cirurgias convencionais ou endovasculares. Descrevemos o caso de um paciente portador de doença oclusiva aortoilíaca extensa tratado com derivação arterial no território ilíaco-femoral, utilizando substituto autógeno alternativo e a artéria descendente femoral lateral como artéria receptora. Derivações e substitutos alternativos, utilizados normalmente em casos de exceção, podem e devem fazer parte do arsenal terapêutico vascular, podendo contribuir nos casos em que a cirurgia endovascular ainda não nos permite alcançar bons resultados.