Comparaison Between Endovascular Approach and Aorto-Bifemoral Bypass for Tasc D Aorto-iliac Disease Patients Treated between 2011-2017.

Introduction: In the last few years, endovascular approaches have been demonstrating remarkable results on the treatment of aortoiliac TASC D lesions. However, the results remain conflictuous and proper evidence regarding the best treatment option for this group of patients is still lacking. Through this work, we aim to compare patency, cost-effectiveness and quality of life in patients successfully treated by these two approaches.

Methods: Patients with TASC D aorto-iliac disease, from two independent Vascular Surgery Centers, treated either by open surgery and endovascular intervention between 2011- 2017, were retrospectively analyzed and consecutively included (n=59). Patients were then divided in 2 groups: Open Group (OG), in which aorto-bifemoral bypass was performed (n=27); and Endo Group (EG), in which an endovascular approach was preferred (n=32). Surgical decision between these two procedures was made individually by the surgeon, according to clinical criteria. Baseline characteristics (age, diabetes, smoking history, chronic kidney disease and rutherford grade of ischemia) were also evaluated. Quality of life (QoL) was later assessed by means of three physical and telephonic validated questionnaires (EQ-5D-5L; peripheral artery questionnaire; walking impairment questionnaire).

Results: There were significant statistical differences between the OG and EG, regarding mean age (62 vs 65 years, p=0,044) and tobacco use (100 vs 75%, p=0,05), but both groups were comparable for the remaining baseline characteristics. Technical success was achieved in 100% of the cases of OG, while only in 65% was it obtained in the EG (p=0,001). Consequently, re-intervention rate was higher in the later. Regarding infection rate, it was significantly higher in the OG (11.1% vs 0%, p=0,05). No differences between groups were found regarding limb salvage (96,3% vs 100%, p> 0,05). Cost-analysis revealed that endovascular procedures were significantly more expensive than open interventions (1053€ vs 2080€, p=0,001), with similar inpatient lengths. Nonetheless, ICU occupation was significantly lower in the EG (3,8 vs 0,05 days, p=0,05). No differences between groups were found in the questionaries of QoL (p>0,05).

Conclusion: Despite higher rates of technical success in the OG, patency and limb salvage seems quite similar between the two techniques. Also, endovascular approach of the aortoiliac sector remains significantly less invasive than the conventional alternative. Based on this, and despite the higher success rate of open surgery, shouldn't we give an opportunity to the "endovascular first" approach?