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Clinical Outcomes of Iliofemoral
Bypasses for Isolated Unilateral
Iliac Occlusive Disease:
A Review
Mohammed M. Moursi, MD
Professor, Vascular Surgery
Division Chief, UAMS Vascular and Endovascular Surgery
Chief, Vascular Surgery, Little Rock VA
Georgia Vascular Society
6th Annual Scientific Sessions
September 14 – 16, 2018
Ritz-Carlton Reynolds, Lake Oconee
Greensboro, GA
15 -Year10 -Year
Nothing to disclose
Iliac occlusive disease
• TASC II committee for the management
of peripheral artery disease
recommended an endovascular approach
over surgery as the preferred treatment
of TASC A and B aortoiliac lesions
• 60-80% 5 year patency
Iliac occlusive disease
• Recommendation for surgical treatment
of TASC C and D lesions in the iliac
system
Arkansas experience
• Excellent atherosclerotic population
• Tended towards operative repair of
isolated severe iliac stenosis and occlusion
via a unilateral retroperitoneal approach
• Including flush occlusions of the common
iliac artery
Patient population
• January 2003 till January 2018
• Single surgeon, single institution
• 102 pts underwent iliofem bypass for
occlusive disease
• Routine follow up consists of ABI every 6
months
• Aneurysmal disease, trauma etc. were
excluded
Follow –up
• 41 month average follow up
Demographics
Factor Value
Age (years) 61
Gender – male (%) 95
BMI 24
Smoking (%) 84
Diabetes (%) 22
Hypertension (%) 84
CAD (%) 23
COPD (%) 32
HPLD (%) 52
Indication %Claudication 58
Rest pain 33
Tissue loss 9
Indications
Previous vascular procedures
Ipsilateral leg
• 23% had previous procedures
• Iliac stents
• Fem endartectomy
• Fem-fem bypass
Concomitant outflow
procedures
• 12%
• Fem pop – above and below knee
• Profunda pop
• SFA thrombectomy/atherectomy
• Gracilis flap
Post-op Complications
• 24% typical types for this population
• Most were wounds
• 2% MI
• 2% Afib
• 2% pneumonia
Patency
• 4 grafts thrombosed within 30 days -
94% patency
• Thrombectomized and remained patent
• 5 additional grafts thrombosed within
one year - 89% one year patency
• 80% three year patency
• 75% five year patency
Patency
• 20 grafts failed in the cohort - several
multiple times
• 16 pts lower ext were revascularized
• thrombectomy of graft – adjunct procedures
• Fem-fem bypass
• 4 pts had thrombosed grafts and were not
revascularized
Patency
• 8 pts were identified with a decreased
ABI and underwent proximal or distal
repair prior to thrombosis
• Regained ABI
Patency – secondary
• Open thrombectomy
• Most will not have a “stump” of contrast
• Flush occlusion
• Will not be able to achieve a good
proximal “endpoint” with fogarty
• Will need proximal stenting
• Protect the contralateral side
Patency – secondary
• Relining the graft with covered stent
graft
• Removal of intimal hyperplasia and
patch angioplasty of distal anastomosis
• Removal of 2 infected grafts and
replacement with deep femoral vein
• Fem-fem bypass graft
0 20 40 60 80 1000
20
40
60
80
100
Days elapsed
Perc
en
t P
ate
nt
Months elapsed
Per
cen
t p
ate
nt
Patency
ABI
• Average increase in ABI was 91%
Mortality
• 2% 30 day mortality
• One year – 93%
• Three year – 75%
• Five year – 60%
0 20 40 60 80 1000
20
40
60
80
100
Days elapsed
Perc
en
t A
live
Per
cen
t ali
ve
Months elapsed
Mortality
Technique
• General anesthesia
• Transplant (hockey stick) incision
• Proper dissection can expose the distal aorta
• Segmented ring fixed retractor
Iliofemoral bypass – conduit
• 8 mm ringed PTFE
Proximal control
• Aortic clamp 22%
• Aortic balloon occlusion via contralateral
femoral 17%
• Remaining – clamp placed on common
iliac
Iliofemoral procedure
proximal anastomosis• Proximal take off site endarterectomized
in nearly all cases
• Common iliac circumferential plaque
removal
• Anterior common iliac longitudinal
arteriotomy with patch angioplasty down to
internal iliac
• Patch
• Hood the graft as patch
• Aortic bifurcation plaque
Iliofemoral bypass
distal endpoint
• Common fem and profunda endarterectomy
• Separate patch
• Hood the graft
• Patch onto the profunda
Iliofemoral bypass
• Excellent option for extensive iliac
disease
• Can treat flush occlusions with aortic
control
• Good patency
• Acceptable morbidity and mortality
Acknowledgments
• Nawar Hudefi
• David Soni
• Victoria Ly
Thank you