Open Surgery or Stenting for Aorto- iliac occlusive ... · • 850% increase in...
Transcript of Open Surgery or Stenting for Aorto- iliac occlusive ... · • 850% increase in...
Open Surgery or Stenting for Aorto-iliac occlusive disease. Which is
best?
Richard GibbsSt Mary’s Regional Vascular Unit
Imperial College NHS TrustLondon UK
Open Bypass Endovascular
• Higher mortality Lower mortality
• High complication rate Low complication rate
• Long hospital stay Short hospital stay
• More durable Less durable
• Young, fit Old, co-morbid
• Gold standard Evolving
Preconceptions
Aortobifemoral Bypass
5 year patency = 82-92%
Aortounifemoral Bypass
5 year patency = 62-78%
Femoro-femoral Cross over
5 year patency = 52-83%
Axillo- bifemoral Bypass
5 year patency = 45-62%
Ileofemoral Bypass
5 year patency = 48-57%
• 850% increase in angioplasty/stenting • 34% increase in the total number of interventions• 15.5% decrease aortofemoral bypass
Survival in patients with PVD
Newman et al. ATVB, 1999
TASC II 2007
Survival in patients with PVD
TASC
• 29 open bypass studies (n=3,733)
• 28 Endo studies (n=1,625)
• TASC C+D
• Open= ABF and endarterectomy
• Endo= angioplasty, balloon/self expanding stents, covered stents
Were the groups comparable?
Endovascular Open p
Claudicants 76% 55% <0.001
CLI 27% 44% <0.001
SFA occlusion 25% 50% <0.001
Renal insufficiency 9% 4% 0.001
Coronary disease 30% 38% 0.005
Pulmonary disease 15% 21% 0.07
Prior vascular intervention
17% 26% 0.126
Open: 2.6%
Endo: 0.7%
Open: 18%
Endo: 13.4%
Complications
Open
• GI 4.9%
• Pulmonary 3.4%
• Stroke 1.1%
• Wound infection 4.6%
• Graft failure 1%
• Cardiac events 4.2%
• Bleeding 1.5%
• Early Thrombosis 3.4%
• Distal Embolization 1.2%
Endovascular
• Stent/vessel occlusion 3.8%
• Pseudoaneurysm 2.6%
• Rupture/perforation 2.4%
• Dissection 3.6%
• Haematoma 4.4%
• Cardiac events 1.7%
• Bleeding 1.9%
• Early Thrombosis 4.9%
• Distal Embolization 4.9%
Durability
Primary patency Open Endovascular p
1 year 95% 86% <0.001
3 years 86% 80% <0.001
5 years 83% 71% <0.001
Secondary patency
1 year 96% 90% <0.002
3 years 92% 87% <0.001
5 years 91% 83% <0.001
‘Endovascular therapies should be considered a first line
treatment option for all patients with aortoiliac disease, especially
those with high risk cardiac comorbidities’
‘In only 2 decades, EVAR was transformed from a procedure exclusively confined to
high risk patients to a primary choice and preferred method for most patients….’
The same paradigm shift from open surgery to complex endovascular
reconstruction is now prevailing for the treatment of aortic occlusion’
TASC D TASC A-C p
Success rate 91.6% 99.3% <0.001
Complications 11.1% 5.2% <0.001
Mortality 0.8% 0.5% 0.463
5 Yr primary patency 77.9% 77.`1% 0.779
5 Yr secondary patency 98.9% 98.1% 0.694
Freedom major amputation 98.5% 99.4% 0.024
Type IV
Peritoneum swept off diaphragm
L crus divided to expose aorta above coeliac
L kidney rotated upwards and to the right
Lateral wall of aorta exposed down to L iliac
Conclusions
• Surgery more durable
• Stenting less invasive
• Age, co-morbidity, lesion extent
• Both modalities needed