Treatment Options for TASC II C and D Aorto-iliac Occlusive Disease: A Systematic Review and Network Meta-analysis

OBJECTIVE: To comprehensively clarify various treatment options for Trans-Atlantic Inter-Society Consensus (TASC) II C and D aorto-iliac occlusive disease (AIOD) through network meta-analysis (NMA), thus offering in-depth perspectives for clinical decision-making. METHODS: A systematic literature search of PubMed, Embase, Cochrane Library, and Web of Science was performed to identify controlled studies of operative treatment for AIOD. After quality assessment of the included studies, an NMA was performed using Stata software for primary outcomes: primary patency rate (1, 2, 3, and 5 years), and secondary outcomes: early postoperative mortality and perioperative complication rates. This study was prospectively registered in PROSPERO (ID: CRD42024535252). RESULTS: Fifteen studies involving 7 surgical treatments were included aorto-femoral bypass (AoFB), axillofemoral bypass (AxFB), femoral-femoral bypass (FFB), aorto-iliac bypass (AIB), kissing covered stent (KS), covered endovascular reconstruction of aortic bifurcation (CERAB), and hybrid surgery. Results of the NMA indicated that compared with AoFB, CERAB had a comparable 1-, 2-, 3-, and 5-year postoperative primary patency rates. The AxFB yielded the lowest 1-year (odds ratio [OR]=0.31, 95% confidence interval [CI]=0.14-0.71) postoperative primary patency rates, and the same trend was maintained at 2-year (OR=0.29, 95% CI=0.15-0.56) and 3-year (OR=0.31, 95% CI=0.14-0.68) post-operation. Surface under the cumulative ranking curve (SUCRA) analysis ranked CERAB the highest for the 2-, 3- and 5-year postoperative primary patency rates (75.9% vs 91.9% vs 87.8%), with AxFB ranking the lowest (7% vs 19.5% vs 22.7%). The AxFB (77.8%) had the highest incidence of perioperative complications, followed by AIB (75.3%), with CERAB (3.7%) ranking the lowest. CONCLUSION: For patients with TASC II C and D AIOD, CERAB demonstrated a comparable durability in primary patency rates with AoFB and fewer perioperative complications than other interventions. The AxFB demonstrated the lowest postoperative primary patency rates and the highest incidence of perioperative complications. However, the mentioned limitations necessitate high-quality research to verify these findings.Clinical ImpactFor patients with TASC II C and D AIOD, CERAB demonstrated a comparable durability in primary patency rates with AoFB and fewer perioperative complications than other interventions. The AxFB demonstrated the lowest postoperative primary patency rates and the highest incidence of perioperative complications.