Iliofemoral endarterectomy associated with systematic iliac stent grafting for the treatment of severe iliofemoral occlusive disease

Objective: Iliofemoral endarterectomy with external iliac artery (EIA) stent grafting can be an alternative to traditional open surgery in patients with severe iliac occlusive disease extending to the common femoral artery. We report the midterm outcomes of this approach. Methods: Between 2009 and 2015, 108 patients (76% male; median age, 63 years) underwent a total of 127 iliofemoral endarterectomies combined with EIA stent grafting. Indications were claudication in 60%, rest pain in 20%, ulceration in 15%, and acute ischemia in 5%. Lesions exclusively involved only the EIA segment in 40% of cases, with occlusion in 28%. Lesions involved both the EIA and common iliac artery segments in 49% of cases, with 19% of common iliac artery occlusions and 24% of EIA occlusions. Iliac lesions extended into the aortic segment in 11% of cases. Iliofemoral endarterectomy was performed by eversion whenever possible. Deployment of the EIA stent graft systematically incorporated the EIA segment and the proximal end of the endarterectomy. Self-expanding covered stents were calibrated to the diameter of the endarterectomized EIA. Results: The procedure was technically successful in 100% of patients. Median diameter of covered stents was 8 mm (range, 6-10 mm). No intraoperative arterial rupture or dissection was observed. Early reoperations (3%) were performed for bleeding, infection, or thrombosis. Median length of stay was 5 days. No 30-day mortality was observed. Median followup was 30 months (range, 0-6 years), and overall mortality was 13% (due to cancer in half of the cases). Repeated angioplasty was performed in three (2%) cases, and a subsequent open procedure on the iliofemoral segment was performed in seven (5%) cases. At 2 years, primary patency rate of the treated segment was 91%. The 2-year primary assisted patency and secondary patency rates were 94% and 98%, respectively. Five-year primary, primary assisted, and secondary patency rates were 87%, 92%, and 98%, respectively. Conclusions: Combined iliofemoral endarterectomy and covered stenting of the EIA for treatment of severe occlusive lesions provided acceptable midterm results, probably because of the gain of diameter provided by covered stents. This technique avoids complications due to an aortic or iliac surgical approach and clamping as well as complications related to the presence of a prosthetic implant in an intra-abdominal position.