Iliofemoral endarterectomy and stenting improves mid-term patency for advanced aortoiliac disease with concomitant common femoral disease

Objective Combined iliofemoral endarterectomy and iliac stenting (IFE + S) is a proven surgical approach for TransAtlantic Inter-society Consensus (TASC) C and D aortoiliac occlusive disease (AIOD). Iliac stenting alone (ISA) may be an attractive, minimally invasive option in select cases; however, untreated moderate-to-severe common femoral disease may threaten iliac stent patency and limit symptom improvement. This study evaluates the mid-term patency rates after IFE + S versus ISA for TASC C and D AIOD as well as the rate of interval femoral endarterectomies in those who underwent ISA. Methods This is a retrospective, single-center analysis of patients from 2011 to 2018 with TASC C or D AIOD and concomitant femoral artery stenosis of >50% who underwent IFE + S or ISA. Baseline lesion and patient characteristics such as TASC classification, degree of stenosis, calcification severity, lesion length, and baseline ankle-brachial index (ABI) were collected. Primary, primary-assisted, and secondary patency rates were calculated over three years with Kaplan-Meier estimates. The rate of interval femoral endarterectomies in the ISA cohort was measured at the same time endpoint. Results Of the 78 limbs identified, 64 (82.1%) underwent IFE + S and 14 (17.9%) underwent ISA. No significant differences in aortoiliac or femoral lesion characteristics existed. Iliac stent primary patency was significantly improved in the IFE + S group at three years [85.1% versus 55.6%, HR 3.96 (95% CI 1.54, 10.2, p = .004)]. Primary-assisted and secondary patency rates were not significantly different. Five (35.7%) patients in the ISA cohort required an interval femoral endarterectomy for ischemic symptoms over the three-year endpoint. Conclusions: In select patient populations with concomitant TASC C or D AIOD and common femoral artery disease, IFE + S may provide improved mid-term primary stent patency when compared to ISA. A subset of patients who undergo ISA may require future femoral endarterectomies for ischemic symptoms.