A systematic review of endovascular treatment of

extensive aortoiliac occlusive disease

Vincent Jongkind, MD,a,b George J. M. Akkersdijk, MD,a Kak K. Yeung, MSc,b and
Willem Wisselink, MD,b Hoofddorp and Amsterdam, The Netherlands

Objectives: Current multidisciplinary guidelines recommend to treat extensive aortoiliac occlusive disease (AIOD) by
surgical revascularization. Surgery provides good long-term patency, but at the cost of substantial perioperative
morbidity. Development of new technologies and techniques has led to increased use of endovascular therapy for
extensive AIOD. We performed a systematic review of the literature to determine contemporary short- and long-term
results of endovascular therapy for extensive AIOD.
Methods: The Medline, Embase, and Cochrane databases were searched to identify all studies reporting endovascular
treatment of extensive AIOD (TransAtlantic Inter-Society Consensus (TASC) type C and D) from January 2000 to June
2009. Two independent observers selected studies for inclusion, assessed the methodologic quality of the included
studies, and performed the data extraction. Outcomes were technical success, clinical success, mortality, complications,
long-term primary, and secondary patency rates.
Results: Nineteen nonrandomized cohort studies reporting on 1711 patients were included. There was substantial clinical
heterogeneity between the studies considering study population and interventional techniques. Technical success was
achieved in 86% to 100% of the patients. Clinical symptoms improved in 83% to 100%. Mortality was described in seven
studies and ranged from 1.2% to 6.7%. Complications were reported in 3% to 45% of the patients. Most common
complications were distal embolization, access site hematomas, pseudoaneurysms, arterial ruptures, and arterial dissec-
tions. The majority of complications could be treated using percutaneous or noninvasive techniques. Four- or 5-year
primary and secondary patency rates ranged from 60% to 86% and 80% to 98%, respectively.
Conclusions: Endovascular treatment of extensive AIOD can be performed successfully by experienced interventionists in
selected patients. Although primary patency rates are lower than those reported for surgical revascularization, reinter-
ventions can often be performed percutaneously, with secondary patency comparable to surgical repair. ( J Vasc Surg
2010;52:1376-83.)

Occlusive disease of the aorta and iliac arteries may lead and B), while extensive disease (TASC type C and D) can be
to incapacitating claudication or critical ischemia. Surgical best treated by reconstructive surgery.8 However, recent
repair in the form of bypass grafting or endarterectomy has device developments and increased experience of interven-
proven effective in relieving symptoms and provides good tionists have prompted the utilization of endovascular ther-
long-term patency. Perioperative morbidity, however, is apy for extensive AIOD. The aim of the present study was
substantial.1-4 Endovascular techniques have been devel- to perform a systematic review of contemporary relevant
oped as a minimal invasive alternative in the treatment of literature on short- and long-term results of endovascular
arterial occlusive disease with reduced morbidity compared therapy for extensive aortoiliac occlusive disease.
with surgical repair. In localized or focal aortoiliac occlusive
disease (AIOD) endovascular therapy using balloon angio-
plasty with or without placement of stents currently is the METHODS
treatment of choice.5-8 A systematic review was performed according to the
The TransAtlantic Inter-Society Consensus (TASC) guidelines of the Meta-analysis Of Observational Studies in
allows classification of AIOD by lesion morphology (Table Epidemiology group (MOOSE) and the Dutch Cochrane
I).7,8 According to the multidisciplinary TASC guidelines, Centre.9,10
published in 2007, endovascular therapy is the preferred Search strategy. Two independent investigators (V.J.
method of treatment for localized disease (TASC type A and K.Y.) performed a computer-assisted search. The med-
From the Department of Surgery, Spaarne Hospital, Hoofddorp,a and ical databases Medline, Embase, and the Cochrane Data-
Department of Surgery, VU University Medical Center, Amsterdam.b base of Systematic Reviews were searched (from January
Competition of interest: none. 2000 to June 2009), using a combination of the following
Reprint requests: Willem Wisselink, MD, Professor of Endovascular Sur-
medical subject headings (MeSH): angioplasty, balloon
gery, VU University Medical Center, PO Box 7057, 1007 MB Amster-
dam, The Netherlands (e-mail: w.wisselink@vumc.nl). angioplasty, arterial occlusive diseases, arteriosclerosis, Le-
The editors and reviewers of this article have no relevant financial relation- riche syndrome, abdominal aorta, and iliac artery. Addi-
ships to disclose per the JVS policy that requires reviewers to decline tionally, a combination of the following free text words was
review of any manuscript for which they may have a competition of used: endovascular, arterial occlusive disease, occlusive dis-
interest.
0741-5214/$36.00
ease, aorta, and iliac artery. Electronic links to related
Copyright © 2010 by the Society for Vascular Surgery. articles and reference lists of selected articles were hand-
doi:10.1016/j.jvs.2010.04.080 searched to retrieve more studies. A hand-search for rele-
1376
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 5 Jongkind et al 1377

Table I. TransAtlantic Inter-Society Consensus (TASC) and Society of Cardiovascular and Interventional Radiology
(SCVIR) classifications8,11

TASC SCVIR

type A type 1
Unilateral or bilateral stenoses of CIA Short segment (⬍2 cm) stenoses of the infrarenal aorta, with
Unilateral or bilateral single short (⬍3 cm) stenosis of EIA minimal atherosclerosis of the aorta otherwise.
Iliac stenoses less than 3 cm in length that are concentric and
noncalcified.
type B type 2
Short (⬍3 cm) stenosis of infrarenal aorta 2-4 cm stenoses of the infrarenal aorta, with mild atherosclerosis of
Unilateral CIA occlusion the aorta otherwise
Single or multiple stenosis totaling 3-10 cm involving the Iliac stenoses 3-5 cm in length or calcified or eccentric stenoses less
EIA not extending into the CFA than 3 cm in length
Unilateral EIA occlusion not involving the origins of
internal iliac or CFA
type C type 3
Bilateral CIA occlusions Long segment (⬎4 cm) stenoses of the infrarenal aorta
Bilateral EIA stenoses 3-10 cm long not extending into Aortic stenosis with atheroembolic disease
the CFA Medium length (2-4) stenoses of the infrarenal aorta, with
Unilateral EIA stenosis extending into the CFA moderate to severe atherosclerosis of the aorta otherwise
Unilateral EIA occlusion that involves the origins of Iliac stenoses 5-10 cm in length
internal iliac and/or CFA
Heavily calcified unilateral EIA occlusion with or without
involvement of origins of internal iliac and/or CFA
type D type 4
Infrarenal aortoiliac occlusion Iliac stenoses greater than 10 cm in length
Diffuse disease involving the aorta and both iliac arteries Chronic iliac occlusions greater than 4 cm in length after
Diffuse multiple stenoses involving the unilateral CIA, thrombolytic therapy
EIA, and CFA Extensive bilateral aortoiliac atherosclerotic disease
Unilateral occlusions of both CIA and EIA Aortic or iliac stenoses in patients with AAA or other lesions
Bilateral occlusions of EIA requiring aortic or iliac surgery
Iliac stenoses in patients with AAA requiring treatment
and not amendable to endograft placement or other
lesions requiring open aortic or iliac surgery
AAA, Abdominal aortic aneurysm; CFA, common femoral artery; CIA, common iliac artery; EIA, external iliac artery.

vant journals and conference proceedings was not per- methods of intervention (ie, use of percutaneous or open
formed. A search was not done for unpublished data or vascular access, use of thrombolysis, or performance of
abstracts. Relevant studies were selected for full text review additional surgical outflow procedures). These differences
based on title and abstract. were accounted for during analysis. Only studies published
Study selection. Studies reporting on endovascular in English or Dutch language were included. Articles had
therapy for extensive AIOD were selected based on full text to describe original patient series to be eligible. Studies
review by two independent authors (V.J. and K.Y.). To be containing duplicate material were excluded. The larger
eligible, studies had to report the morphology of aortoiliac study, containing the best documented data, was included
occlusive lesions, preferably but not exclusively based upon for analysis. Review articles, technical descriptions, case
the TASC guidelines.7,8 Extensive AIOD was defined as reports, and small patient series (N ⬍ 10) were excluded.
TASC type C or D lesions (Table I). Alternatively, guide- Methodologic quality assessment. Two investiga-
lines of the Society of Cardiovascular and Interventional tors (V.J. and K.Y.) independently assessed the method-
Radiology (SCVIR) could be used for classification of ologic quality of each included study using a critical review
AIOD.11 SCVIR categories 3 and 4 for iliac artery and checklist.9 Study quality was assessed in two ways. First, the
aortic angioplasty were considered extensive AIOD (Table fulfillment of seven requirements was determined: a clear
I). Studies that did not use TASC or SCVIR classifications definition of the study population, exclusion of selection
could be included only if morphology of aortoiliac occlu- bias, clear description of method of intervention, detailed
sive lesions was accurately described, and extensive AIOD description of outcome, data collection by independent or
could be assumed by both investigators. Studies reporting blinded observers, no selective loss of patients to follow-up,
combined results of localized and extensive AIOD were and description of confounders. Furthermore, all studies
eligible only if independent results of extensive AIOD were evaluated using a list of detailed study characteristics
could be retrieved or if the majority of the lesions depicted as proposed by the MOOSE group.10 Each item was
extensive disease. To provide a comprehensive overview all graded on a scale of 0 to 2 depending on the information
studies reporting on endovascular treatment of extensive available in the article. Quality score was determined by
AIOD were included, regardless of differences in their whether the study reported a consecutive series, a prospec-
 JOURNAL OF VASCULAR SURGERY
1378 Jongkind et al November 2010

was used.28,38 Two studies did not use a classification

system,32,34 but sufficiently described the morphology of
aortoiliac lesions in their patient group to consider them
“extensive”. In total 1711 patients were evaluated of
which 1329 patients had extensive AIOD. From eight
studies, specific data on extensive AIOD could be deri-
ved,22,23,25,30,33,35,36,39 while 11 studies reported com-
bined results for extensive and localized AIOD. Three
studies specifically reported on aortic occlusive disease.32-34
Eleven studies were performed in Europe, seven in the
United States, and one in Korea.
Study quality. Results of the methodologic quality as-
Fig. Flow chart illustrating study selection. sessment are presented in Table II. No prospective studies or
randomized trials were found. All studies reported results
tive series, description of excluded patients and reasons for from a single center. In a majority of the studies, selection bias
exclusion, indication for intervention, detailed description could not be excluded. Patient selection varied between the
of complications, and mortality. Methodologic quality was studies: endovascular treatment of extensive AIOD was per-
not an exclusion criterion. formed as treatment of choice,30,31,36,39 or because patients
Data extraction. Data were extracted by two authors were unfit for open surgical repair.22,26,29,32,37 Some studies
(V.J. and K.Y.) independently using a standardized form. excluded patients with disease extending into the common
In case of disagreement, repeat review of the studies in femoral artery or aorta,23,24 while other studies excluded
question was performed. If recorded, the following infor- patients with extensive calcified lesions.30 Also, the use of
mation was extracted from the included studies: publica- hybrid techniques (combining surgery with endovascular
tion year, country of origin, number of patients, and study techniques) varied between the studies. Because of the heter-
design. In addition, the following data were extracted: ogeneity of the studies, pooling of data was not considered
patient characteristics, morphology of aortoiliac occlusive appropriate.
lesions, detailed method of intervention, technical success, Methods of intervention. Endovascular treatment of
clinical success, mortality and morbidity rates, and primary, extensive AIOD was mostly performed using percutaneous
primary-assisted and secondary patency rates. If the study techniques. In two studies, an open technique was used for
described combined results for limited and extensive endovascular access.22,25 Additional surgical outflow pro-
AIOD, only data for extensive disease were extracted, if cedures, including endarterectomy of the common femoral
possible. artery, femoro-femoral bypass, or femoro-popliteal bypass,
Any discrepancies in judgment considering search strat- were performed in 10 studies.23,26,27,30,31,34-37,40 In one
egy, selection of papers, quality assessment, or data extrac- study, this was performed in a second interventional ses-
tion were resolved by discussion between the authors. Final sion.23 Traditionally, a transfemoral approach was used for
decisions were made after consensus was reached. endovascular therapy. In some patients, a transbrachial
access was used for additional endovascular access.24,25,30-32,34
Moise et al used the left brachial artery as standard access
RESULTS point in all patients because of the ease of engaging both
The search identified 488 articles of which 73 studies iliac systems via this route.33
were selected for full text review based on title and abstract. To facilitate recanalization and angioplasty or stenting
Fifty-four studies were excluded after full text review. Study of stenosed or occluded arterial segments intra-arterial
flow and reasons for exclusion are presented in the Figure. thrombolysis was used in selected patients by some au-
Four technical reports, three small case series and one thors.31,33,34,36 Incidentally, debulking of thrombus in
review article were excluded.12-19 Two studies reported on case of occlusion or severe long stenoses has been per-
similar databases and were excluded.20,21 Twenty-four formed using a excimer laser catheter.23,38 Primary stenting
studies reported solely on localized AIOD or reported on a was performed in most studies, while selective placement of
different study group and were also excluded. Thirty-one stents was performed in four studies only.27,33,36,39 Indi-
studies reported combined results of localized and exten- cations for stent placement in these studies were occlusions,
sive AIOD. As specific results for extensive AIOD could not complex or large plaques, or unsatisfactory technical results
be retrieved from 20 studies, these were excluded. Nine- after balloon angioplasty alone. Stenting was performed
teen studies were included in the systematic review.22-40 using a variety of bare stents or endografts. In general,
Four studies originated from two study groups but con- balloon-expandable stents were used in heavily calcified
sidered different patient groups and were not exclu- lesions, while self-expanding stents were preferred in longer
ded.25,31,33,37 The chance adjusted inter-reviewer agree- noncalcified lesions.
ment for study eligibility (␬) was 0.76. Outcomes. Outcomes are depicted in Table III.
Fifteen studies used TASC classification to describe Technical success was reported in all studies and was
aortoiliac lesions, while in two studies SCVIR classification mostly defined as less then 30% residual diameter stenosis
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 5 Jongkind et al 1379

Table II. Quality assessment of included studies

No No selective Quality score of

Study selection Method of Description Independent loss to Description of description of study
First author Year population bias intervention of outcomes observers follow-up confounders characteristics

Nyman 2000 ⫹⫺ ⫹ ⫹ ⫹ ⫺ ⫺ ⫺ 7
Scheinert 2001 ⫹⫺ ⫺ ⫹ ⫹ ⫺ ⫹ ⫹ 9
Ali 2003 ⫹ ⫺ ⫹ ⫹ ⫺ ⫹ ⫺ 8
Greiner 2003 ⫹⫺ ⫺ ⫹ ⫹ ⫺ ⫹ ⫺ 6
Rzucidlo 2003 ⫹⫺ ⫹⫺ ⫹ ⫹ ⫺ ⫹ ⫹ 9
Domanin 2005 ⫹⫺ ⫺ ⫹ ⫹⫺ ⫺ ⫹ ⫹⫺ 9
Lagana 2006 ⫹⫺ ⫺ ⫹ ⫹⫺ ⫺ ⫹ ⫺ 8
Ballzer 2006 ⫹ ⫹ ⫹ ⫹ ⫺ ⫹ ⫹ 9
De Roeck 2006 ⫹⫺ ⫺ ⫹ ⫹ ⫺ ⫹ ⫹ 9
Park 2007 ⫹⫺ ⫹ ⫹ ⫹⫺ ⫺ ⫹ ⫹ 7
Piffaretti 2007 ⫹ ⫹⫺ ⫹ ⫹⫺ ⫺ ⫹ ⫹ 7
Bjorses 2008 ⫹⫺ ⫹⫺ ⫹ ⫹ ⫺ ⫹ ⫹ 10
Chang 2008 ⫹ ⫺ ⫹ ⫹⫺ ⫺ ⫹ ⫹ 9
Gandini 2008 ⫹⫺ ⫺ ⫹⫺ ⫹ ⫺ ⫹ ⫹ 9
Hans 2008 ⫹ ⫺ ⫹ ⫹⫺ ⫺ ⫹ ⫺ 8
Sixt 2008 ⫹⫺ ⫹ ⫹ ⫹ ⫺ ⫹ ⫹ 7
Sharafuddin 2008 ⫹⫺ ⫹⫺ ⫹ ⫹ ⫺ ⫹ ⫹ 7
Kashyap 2008 ⫹⫺ ⫺ ⫹ ⫹⫺ ⫺ ⫹ ⫹ 6
Moise 2009 ⫹ ⫹ ⫹ ⫹⫺ ⫺ ⫺ ⫺ 8
Quality assessment list of the included studies, depicting whether the articles fulfilled the requirements as stated in the Methods section. ⫹ ⫽ yes, ⫺ ⫽ no. A
separate quality score was determined based upon the description of study characteristics. Maximum score was 12.

Table III. Summary of data obtained from the included studies

Age, Technical Clinical Length of

mean Male success improvement Mortality Morbidity Follow-up, stay,
First author Year N N eAIOD y (%) (%) (%) (%) 30 d (%) mean mo mean d

Nymana 2000 30 21 61 43 93 83 6.7 27 19/11g 2median

Scheinerta 2001 212 212b 60 78 90 88 0 11 31 4.8
Ali 2003 22 22 63 91 95 100 0 NS 12 NS
Greinera 2003 25 23 NS 60 86 88 0 NS 16 NS
Rzucidloa 2003 34 29 63 62 100 97 3 3 21max NS
Domanina 2005 42 28 60 71 100 100 0 12 NS NS
Laganaa 2006 19 11 66 63 95 NS 0 21 20 3.2
Ballzer 2006 89 89 64 72 97 92 0 16 36 NS
De Roecka 2006 38 26 59 89 97 100 3 5 26 NS
Park 2007 218 66 64d 95 98d NS 0 6d 30d NS
Piffaretti 2007 43 43 66 70 100 NS 0 5f 32 4.1
Bjorsesa 2008 173 88 64 46 99 86 1.2 14 36 NS
Chang 2008 171 171 67 62 98 92 2.3 22 24median 2median
Gandinia 2008 138 138c 63 75 99 99 0 7 108 NS
Hans 2008 40 40 59 60 95 NS 0 15 32 1
Sixt 2008 375 179 63 80 96 70e 0 NR NS NS
Sharafuddina 2008 66 47 64 70 94 NS 4.5 14 37median NS
Kashyapa 2008 83 65 64 57 96 NS 3.6 16 21 NS
Moise 2009 31 31 65 29 93 NS 0 45 12 3median
N eAIOD, Number of patients with extensive aortoiliac occlusive disease (AIOD); NR, data not retrievable for patients with extensive AIOD; NS, not stated
in the article.
a
Combined report of limited and extensive AIOD.
b
SCVIR classification: class III in 46 patients and class IV in 166 patients.
c
SCVIR classification: class III in 71 patients and class IV in 79 patients.
d
Combined results of limited and extensive AIOD.
e
Measured after one year follow-up.
f
Only major morbidity.
g
for stenoses and occlusions respectively.

and/or a residual translesion pressure gradient of less Nyman et al.34 Reported technical success ranged from 86%
than 5 or 10 mm Hg.22-28,32,35-40 In addition, a marked to 100%. Most common reasons for technical failure were
reduction of the translesion pressure gradient compared with inability to cross an occluded arterial segment, thrombosis
pretreatment values was also considered as technical success by after recanalization, or iliac artery rupture.
 JOURNAL OF VASCULAR SURGERY
1380 Jongkind et al November 2010

Table IV. Primary and secondary patency rates

1 year 2 year 3 year 4 year 5 year

First author Year PP (%) SP (%) PP (%) SP (%) PP (%) SP (%) PP (%) SP (%) PP (%) SP (%)

Nyman 2000 97 100a

Scheinert 2001 84 88 81 88 78 86 76 85 66 80
Ali 2003 84 95b
Greiner 2003 91a 65a
Rzucidlo 2003 70 88
Domanin 2005 70 88
Lagana 2006 89 100
Ballzer 2006 90 96
De Roeck 2006 94 100 89 94 89 94 77 94 77 94
Park 2007 C 94 C 97 C 94 C 97a C 78 C 74a
D 93 D 94 D 74 D 85a D 74 D 85a
Piffaretti 2007 92 86 81
Bjorses 2008 97 100 88 97 83 95 74 91 65 83
Chang 2008 60 98
Gandini 2008 95 97 93 96 91 94 88 93 86 90
Hans 2008 69 89
Sixt 2008 C 86 C 98
D 85 D 98
Sharafuddin 2008 81 94a
Kashyap 2008 90 97 82 97 74 95
Moise 2009 85 100 66 90
C, Results for patients with TASC type C lesions; D, results for patients with TASC type D lesions; PP, primary patency; SP, secondary patency.
a
primary assisted patency.
b
limb salvage rate.

Eleven studies reported clinical outcome directly and 88% to100%, respectively. Four- or 5-year primary
postintervention or at first follow-up visit. Clinical symp- and secondary patency rates could be derived from eight
toms improved in 83% to 100% of the patients. In one studies and ranged from 60% to 86% and 80% to 98%,
study, change of clinical symptoms for individual patients respectively.
was reported only after 1-year follow-up, improvement was Two studies retrospectively compared endovascular
recorded in 70% of the patients.39 therapy and open surgical reconstruction for extensive
Mortality was reported in all included studies. In 12 AIOD.30,31 Choice of treatment was performed by the
studies, no perioperative or 30-day mortality was found, surgeon or interventionist treating the patient. Patients
while seven studies reported a mortality rate ranging from who had severe calcifications were not considered for
1.2% to 6.7% (Table II). In addition to mortality, morbidity stenting by Hans et al, but no further considerations for
rates could be derived from 16 studies. One study only treatment allocation were mentioned. Patients undergo-
reported major complications.36 Reported morbidity rate ing endovascular therapy were older but had similar
ranged widely between the other 15 studies (range, 3% to
clinical variables as patients undergoing surgical repair.
45%). Most common reported complications were access
Mortality did not differ between the groups in both
site hematomas (reported in 7 studies, range, 4% to 17%),
studies, as did morbidity in the study of Kashyap et al.
distal embolization (reported in 10 studies, range 1% to
Hans et al reported substantial perioperative morbidity
11%), arterial dissections (reported in 7 studies, range, 2%
in the open surgery group (pulmonary complications in
to 5%), pseudoaneurysms (reported in 10 studies, range
0.5% to 3%), and iliac artery or aortic ruptures (reported in 13%, cardiac 9%, other systemic complications in 16%
7 studies, range 0.5% to 3%). The majority of complications and 6% local wound complications).30 In the endovascu-
could be treated using percutaneous or noninvasive tech- lar group, intraprocedural complications occurred in
niques. Arterial dissections and ruptures were mostly 10%, which could all be solved with percutaneous tech-
treated by (covered) stent placement, while distal em- niques, while two patients experienced access-related
bolization was treated by aspiration or thromboly- complications which could be treated conservatively.
sis.24,25,27,28,30,40 Surgical repair was required to treat less Length of stay was measured by Hans et al and was
then half of the patients with pseudoaneurysms and a few of significantly shorter for the endovascular group (1 vs 7
the patients with access site hematomas or vessel rupture. days). Both studies reported significantly lower long-
Length of stay was reported by seven studies and ranged term primary patency for endovascular therapy (69% vs
from 1 to 4.8 days. 93%, P ⫽ .01330 and 74% vs 93%, P ⫽ .002 31). Second-
Patency results are presented in Table IV. One-year ary patency did not differ significantly, however (89% vs
primary and secondary patency ranged from 70% to 97% 100%, P ⬎ .05 30 and 96% vs 96%31).
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 5 Jongkind et al 1381

DISCUSSION that only one study reported a mean follow-up of more

Endovascular therapy currently has been firmly estab- than 5 years.
lished as the treatment of choice for localized aortoiliac Several factors that may influence long-term patency
occlusive disease. The role of endovascular techniques in after endovascular therapy of AIOD were analyzed in the
included studies, including stent placement, lesion mor-
the management of extensive and complex aortoiliac dis-
phology, and outflow. The Dutch Iliac Stent Trial, a ran-
ease, on the other hand, is still controversial. For these
domized study comparing primary stenting of AIOD with
patients, the TASC multidisciplinary guidelines recom-
selective stent placement, has shown similar late patency for
mend operative reconstruction, unless operative risk is pro-
both groups, with lower costs in the selective stenting
hibitive.8 Long-term patency rates of aortobifemoral
group.41 Despite this, primary stenting was preferred in
bypass graft or aortoiliac endarterectomy are excellent
most studies for extensive aortoiliac lesions. Arguments in
(85%-92%), with modest operative mortality.1-4 However,
favor of primary stent placements were that stent deploy-
perioperative morbidity of surgical revascularization is sub-
ment without predilatation (direct stenting), not only re-
stantial, while the time-period before return to normal
duces the risk of vessel rupture, but also decreases the risk of
activities and the effects on sexual function are also impor-
distal embolism.23,30,32,34 Three studies analyzed the influ-
tant to consider. Systemic or major morbidity rates are
ence of stent placement on long-term patency. Neither
reported up to 10%, with overall morbidity 11% to 32%.
Domanin et al27 nor Pifaretti et al36 found a statistically
Endovascular treatment is a less invasive management
significant difference in primary patency between patients
option, potentially reducing morbidity. Moreover, when
receiving stent grafting or treated by balloon angioplasty
the outcome does not meet expectations, patients may still
alone. In contrast, Sixt et al39 found that the 1-year primary
be referred for conventional surgical therapy without much
patency rate after stenting was significantly better com-
“lost”. The development of new technologies and tech-
pared to balloon angioplasty alone.
niques has led to increasing use of endovascular techniques Several studies analyzed the influence of lesion mor-
in the treatment of extensive AIOD. A systematic search phology on long-term results. One study found that pri-
revealed 19 clinical studies reporting on endovascular treat- mary and assisted primary patency rates were significantly
ment of extensive AIOD. In this heterogenic group of lower for iliac artery occlusions over 10 cm in length
studies, selected patients with extensive AIOD could be compared with those for occlusions less than 10 cm in
treated using endovascular techniques with good technical length.38 On the other hand, none of the other studies
success rates. Despite the use of various endovascular tech- found a significant difference between localized vs extensive
niques, technical success was reported over 90% in all but aortoiliac disease.24,26,31,35,39,40 Distal outflow may influ-
one study. ence primary patency as is pointed out by several au-
There was a wide range in reported complication rates. thors.29,30,39 To improve outflow, infrainguinal revascular-
This variation may be caused by varying interventional ization was performed in a small majority of the studies.
techniques and different study populations, sometimes Aside from endovascular therapy, other alternatives for
with multiple comorbidities. Furthermore, the retrospec- open surgery are axillobifemoral bypass or (robot-assisted)
tive nature of the studies may have led to under reporting. laparoscopic aortic surgery. Operative morbidity is reduced
Although reported complication rates were considerable, after axillobifemoral bypass, but durability is also substan-
most complications could be treated percutaneously or tially lower.42,43 Laparoscopic aortic surgery without or
conservatively. The use of multiple access sites, perfor- with robot-assistance has been developed as a minimal
mance of additional surgical revascularization procedures, invasive option for AIOD, reducing operative trauma and
and high incidence of comorbidities in most studies may facilitating quicker ambulation.44-46 Long-term follow-up
have increased the risk for complications. The high mor- results are scarce, however, and more data are required to
bidity rate reported by Moise et al (45%) is partly due to define the value of (robot-assisted) laparoscopic aortic sur-
access site complications at the brachial artery occurring in gery.
5 of 31 patients.33 In total, the majority of reported com- Several limitations to our study need to be addressed.
plications were technical, such as iliac artery injury, distal To retrieve recent literature we have restricted our system-
embolization, and access site complications. Growing ex- atic search to studies published after January 2000. Due to
perience and advances in development of endovascular this time constriction, relevant studies could have been
devices will probably reduce these complications. missed by our search. However, the multidisciplinary
Long-term primary patency rates following endovascu- TASC guidelines, published in 2007, already considered
lar treatment cannot yet compete with those reported for relevant literature to that date. The aim of this systematic
open reconstructive surgery. Nevertheless, reinterventions review was to retrieve relevant data not yet considered in
following loss of primary patency after endovascular ther- TASC guidelines. Furthermore, the majority of the studies
apy could be performed using percutaneous techniques in included in this review were published in the last 2 years.
the majority of patients, obtaining secondary patency rates The TASC classification for lesion morphology was
of 80% to 98%. Hereby, the minimal invasive character of used by the far majority of studies published on AIOD in
the intervention has been maintained, with avoidance of the last decade. In some studies, however, other or no
surgery with concomitant risks. It needs to be considered classification systems are used. To achieve more studies,
 JOURNAL OF VASCULAR SURGERY
1382 Jongkind et al November 2010

those using other or no classification were also included in AUTHOR CONTRIBUTIONS

this review, inevitably leading to increased heterogeneity Conception and design: VJ, GA, WW
between the included studies and decreased accuracy for Analysis and interpretation: VJ, GA, KY, WW
determining extensive AIOD. Data collection: VJ, KY
Most studies included in this systematic review origi- Writing the article: VJ, GA
nate from tertiary referral centers or centers of excellence Critical revision of the article: KY, WW
reporting on selected patients. The results reported by Final approval of the article: VJ, GA, KY, WW
these studies may not be applicable to other centers. In Statistical analysis: VJ
several studies, endovascular therapy was not the primary Obtained funding: Not applicable
treatment for extensive AIOD, but offered to patients with Overall responsibility: VJ
significant comorbidities unsuitable for surgical repair. Fur-
thermore, only selected patients suitable for endovascular
REFERENCES
treatment were reported, while exclusion criteria for endo-
vascular treatment were often not mentioned. All studies 1. de Vries SO, Hunink MG. Results of aortic bifurcation grafts for
aortoiliac occlusive disease: a meta-analysis. J Vasc Surg 1997;46:558-
were retrospective and most included a small number of 69.
patients, precluding adequate subgroup analysis and limit- 2. Reed AB, Conte MS, Donaldson MC, Mannick JA, Whittemore AD,
ing the value of statistical analysis. Because of these short- Belkin M. The impact of patient age and aortic size on the results of
comings, it is difficult to make recommendations regarding aortobifemoral bypass grafting. J Vasc Surg 2003;37:1219-25.
3. Naylor AR, Ah-See AK, Engeset J. Aortoiliac endarterectomy: an 11-
technique or patient selection. Despite this, the results year review. Br J Surg 1990;77:190-3.
from the included studies suggest that most occlusions and 4. Urayama H, Ohtake H, Yokoi K, Fujimori H, Kawaguchi M, Ishikawa
long stenoses can be recanalyzed without the need for T, et al. Long-term results of endarterectomy, anatomic bypass and
thrombolysis or laser catheters. Next, in complex lesions, extra-anatomic bypass for aortoiliac occlusive disease. Surg Today 1998;
28:151-5.
stent placement is mostly preferred over balloon angio- 5. Bosch JL, Hunink MG. Meta-analysis of the results of percutaneous
plasty alone. Regarding patient selection some authors transluminal angioplasty and stent placement for aortoiliac occlusive
point out that recanalization of heavy calcified occlusions disease. Radiology 1997;204:87-96.
can be challenging, with a higher risk of vessel rupture 6. Galaria II, Davies MG. Percutaneous transluminal revascularization for
iliac occlusive disease: long-term outcomes in TransAtlantic Inter-
during dilatation.24,25,30 For these lesions, the use of cov- Society Consensus A and B lesions. Ann Vasc Surg 2005;19:352-60.
ered stent grafts could prove advantageous.24,25 However, 7. Dormandy JA, Rutherford RB. Management of peripheral arterial dis-
data from controlled trials is necessary to support these ease (PAD). TASC Working Group. TransAtlantic Inter-Society Con-
opinions. sensus (TASC). J Vasc Surg 2000;31:S1-296.
8. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes
The TASC criteria provide a classification system, FG. Inter-Society Consensus for the Management of Peripheral Arterial
which can be used to compare outcomes between stud- Disease (TASC II). J Vasc Surg 2007;45:S5-67.
ies. However, the recommendations of the TransAtlantic 9. Checklist for reporting a systematic review of observational studies.
Inter-Society Consensus seem in need of reconsidera- Available at http://www.cochrane.nl/Files/documents/Checklists/
SR-Obs.pdf. Accessed December 21, 2009.
tion. Although it is not yet clear if all AIOD lesions are 10. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D,
amendable for endovascular therapy, over 1000 patients et al. Meta-analysis of observational studies in epidemiology: a proposal
included in this review have been successfully treated for reporting. Meta-analysis Of Observational Studies in Epidemiology
(MOOSE) group. JAMA 2000;283:2008-12.
with endovascular techniques, while according to TASC
11. Guidelines for percutaneous transluminal angioplasty. Standards of
guidelines surgical revascularization should have been Practice Committee of the Society of Cardiovascular and Interventional
the preferred treatment. Radiology. Radiology 1990;14:619-26.
In conclusion, endovascular treatment of extensive 12. Dosluoglu HH, Cherr GS. Pre-arteriotomy guidewire access (PAGA): a
crucial maneuver for securing inflow and/or outflow in patients with
AIOD can be performed safely and effectively in multiple
bulky iliofemoral occlusive disease undergoing combined (open/
centers worldwide. In the hands of experienced interven- endovascular) procedures. Eur J Vasc Endovasc Surg 2006;32:97-100.
tionists, technical success rates are high with modest mor- 13. Dosluoglu HH, Harris LM, Cherr GS. Recanalization of concomitant
bidity. Although primary patency rates of endovascular iliac artery and common femoral artery occlusions using an antegrade
hybrid (open/endovascular) approach. Vasc Endovascular Surg 2007;
techniques were inferior to those of open revascularization,
41:130-4.
reinterventions could often be performed percutaneously. 14. Brittenden J, Beattie G, Bradbury AW. Outcome of iliac kissing stents.
Secondary patency rates are comparable to surgical repair, Eur J Vasc Endovasc Surg 2001;22:466-8.
but length of follow-up after endovascular techniques is still 15. Jacobs DL, Motaganahalli RL, Cox DE, Wittgen CM, Peterson GJ.
True lumen re-entry devices facilitate subintimal angioplasty and stent-
limited. Larger and prospective studies are required to
ing of total chronic occlusions: initial report. J Vasc Surg 2006;43:
confirm the potential advantages of endovascular treatment 1291-6.
over surgery for extensive AIOD. Nevertheless, with con- 16. Kawasaki D, Tsujino T, Fujii K, Masutani M, Ohyanagi M, Masuyama
tinuing developments in endovascular techniques and de- T. Novel use of ultrasound guidance for recanalization of iliac, femoral,
and popliteal arteries. Catheter Cardiovasc Intervent 2008;71:727-33.
vices as well as growing experience of interventionalists,
17. Klonaris C, Katsargyris A, Tsekouras N, Alexandrou A, Giannopoulos
indications for endovascular treatment of extensive AIOD A, Bastounis E. Primary stenting for aortic lesions: from single stenoses
will be broadened. to total aortoiliac occlusions. J Vasc Surg 2008;47:310-7.
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 5 Jongkind et al 1383

18. Rigatelli G, Cardaioli P. Aorto-iliac endovascular reconstruction by 33. Moise MA, Alvarez-Tostado JA, Clair DG, Greenberg RK, Lyden SP,
kissing stenting through bilateral brachial access. Cardiovasc Intervent Srivastava SD, et al. Endovascular management of chronic infrarenal
Radiol 2007;30:806-8. aortic occlusion. J Endovasc Ther 2009;16:84-92.
19. Sharafuddin MJ, Hoballah JJ, Kresowik TF, Sharp WJ. Kissing stent 34. Nyman U, Uher P, Lindh M, Lindblad B, Ivancev K. Primary stenting
reconstruction of the aortoiliac bifurcation. Perspect Vasc Surg Endo- in infrarenal aortic occlusive disease. Cardiovasc Intervent Radiol 2000;
vasc Ther 2008;20:50-60. 23:97-108.
20. Leville CD, Kashyap VS, Clair DG, Bena JF, Lyden SP, Greenberg RK, 35. Park KB, Do YS, Kim DI, Kim DK, Kim YW, Shin SW, et al. The
et al. Endovascular management of iliac artery occlusions: extending TransAtlantic InterSociety Consensus (TASC) classification system in
treatment to TransAtlantic Inter-Society Consensus class C and D iliac arterial stent placement: long-term patency and clinical limitations.
patients. J Vasc Surg 2006;43:32-9. J Vasc Intervent Radiol 2007;18:193-201.
21. Nelson PR, Powell RJ, Schermerhorn ML, Fillinger MF, Zwolak RM, 36. Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Lagana D, Carrafiello G,
Walsh DB, et al. Early results of external iliac artery stenting combined et al. Mid-term results of endovascular reconstruction for aorto-iliac
with common femoral artery endarterectomy. J Vasc Surg 2002; obstructive disease. Int Angiol 2007;26:18-25.
35:1107-13. 37. Rzucidlo EM, Powell RJ, Zwolak RM, Fillinger MF, Walsh DB,
22. Ali AT, Modrall JG, Lopez J, Brawley JG, Welborn MB, Clagett GP, et Schermerhorn ML, et al. Early results of stent-grafting to treat diffuse
al. Emerging role of endovascular grafts in complex aortoiliac occlusive aortoiliac occlusive disease. J Vasc Surg 2003;37:1175-80.
disease. J Vasc Surg 2003;38:486-91. 38. Scheinert D, Schroder M, Ludwig J, Braunlich S, Mockel M, Flachska-
23. Balzer JO, Gastinger V, Ritter R, Herzog C, Mack MG, Schmitz-Rixen mpf FA, et al. Stent-supported recanalization of chronic iliac artery
T, et al. Percutaneous interventional reconstruction of the iliac arteries: occlusions. Am J Med 2001;110:708-15.
primary and long-term success rate in selected TASC C and D lesions. 39. Sixt S, Alawied AK, Rastan A, Schwarzwalder U, Kleim M, Noory E, et
Eur Radiol 2006;16:124-31. al. Acute and long-term outcome of endovascular therapy for aortoiliac
24. Bjorses K, Ivancev K, Riva L, Manjer J, Uher P, Resch T. Kissing stents occlusive lesions stratified according to the TASC classification: a single-
in the aortic bifurcation–a valid reconstruction for aorto-iliac occlusive center experience. J Endovasc Ther 2008;15:408-16.
disease. Eur J Vasc Endovasc Surg 2008;36:424-31. 40. Sharafuddin MJ, Hoballah JJ, Kresowik TF, Sharp WJ, Golzarian J, Sun
25. Chang RW, Goodney PP, Baek JH, Nolan BW, Rzucidlo EM, Powell S, et al. Long-term outcome following stent reconstruction of the aortic
RJ. Long-term results of combined common femoral endarterectomy bifurcation and the role of geometric determinants. Ann Vasc Surg
and iliac stenting/stent grafting for occlusive disease. J Vasc Surg 2008;22:346-57.
2008;48:362-7. 41. Klein WM, van der Graaf Y, Seegers J, Spithoven JH, Buskens E, van
26. De Roeck A, Hendriks JM, Delrue F, Lauwers P, Van Schil P, De Baal JG, et al. Dutch iliac stent trial: long-term results in patients
Maeseneer M, et al. Long-term results of primary stenting for long and randomized for primary or selective stent placement. Radiology 2006;
complex iliac artery occlusions. Acta Chir Belg 2006;106:187-92. 238:734-44.
27. Domanin M, Crippa M, Talarico M, Costantini A, Molarini A, Agrifo- 42. Martin D, Katz SG. Axillo-femoral bypass for aortoiliac occlusive dis-
glio G. Endovascular treatment of complex atherosclerotic lesions of the ease. Am J Surg 2000;180:100-3.
aortoiliac segment. J Vasc Endovasc Surg 2005;12:9-16. 43. Onohara T, Komori K, Kume M, Ishida M, Ohta S, Takeuchi K, et al.
28. Gandini R, Fabiano S, Chiocchi M, Chiappa R, Simonetti G. Percuta- Multivariate analysis of long-term results after an axillobifemoral and
neous treatment in iliac artery occlusion: long-term results. Cardiovasc aortobifemoral bypass in patients with aortoiliac occlusive disease.
Intervent Radiol 2008;31:1069-76. J Cardiovasc Surg (Torino) 2000;41:905-10.
29. Greiner A, Dessl A, Klein-Weigel P, Neuhauser B, Perkmann R, Wal- 44. Nio D, Diks J, Bemelman WA, Wisselink W, Legemate DA. Laparo-
denberger P, et al. Kissing stents for treatment of complex aortoiliac scopic vascular surgery: a systematic review. Eur J Vasc Endovasc Surg
disease. Eur J Vasc Endovasc Surg 2003;26:161-5. 2007;33:263-71.
30. Hans SS, DeSantis D, Siddiqui R, Khoury M. Results of endovascular 45. Diks J, Nio D, Jongkind V, Cuesta MA, Rauwerda JA, Wisselink W.
therapy and aortobifemoral grafting for Transatlantic Inter-Society type Robot-assisted laparoscopic surgery of the infrarenal aorta: the early
C and D aortoiliac occlusive disease. Surgery 2008;144:583-9. learning curve. Surg Endosc 2007;21:1760-3.
31. Kashyap VS, Pavkov ML, Bena JF, Sarac TP, O’Hara PJ, Lyden SP, et 46. Stadler P, Dvoracek L, Vitasek P, Matous P. Is robotic surgery appro-
al. The management of severe aortoiliac occlusive disease: endovascular priate for vascular procedures? Report of 100 aortoiliac cases. Eur J Vasc
therapy rivals open reconstruction. J Vasc Surg 2008;48:1451-7. Endovasc Surg 2008;36:401-4.
32. Lagana D, Carrafiello G, Mangini M, Lumia D, Caronno R, Castelli P,
et al. Endovascular treatment of steno-occlusions of the infrarenal
abdominal aorta. Radiol Med 2006;111:949-58. Submitted Feb 27, 2010; accepted Apr 30, 2010.