title: Hybrid external iliac selective endarterectomy surgical technique and outcomes.
abstract: OBJECTIVE
  Long or multisegmental external iliac-to-femoral arterial lesions treated by angioplasty and stenting have achieved disappointing results. Conventional, open approaches are often complicated by significant morbidity, and endovascular stenting alone typically requires additional outflow procedures. We hypothesized that a hybrid approach, combining endovascular techniques with remote selective external iliac endarterectomy, produces superior outcomes in terms of patency compared with stenting alone, with minimal associated morbidity.
  
  
  METHODS
  We performed a retrospective review of all patients having undergone hybrid-based retrograde iliofemoral endarterectomy from 2010 to 2014 at St. Joseph Mercy in Ann Arbor, Michigan. Patient demographics, presenting complaints, operative details, and complications were analyzed. Postoperative patency was assessed by comparison of ankle-brachial index values and qualitative patient improvement. Data were analyzed by way of paired Student t-test with significance defined as P < .05.
  
  
  RESULTS
  A total of 40 limbs were intervened upon on 33 patients. In 20 limbs, the procedure was performed for critical limb ischemia (rest pain, n = 9; tissue loss/gangrene, n = 11). By TransAtlantic Inter-Society Consensus II criteria, 83% of iliac lesions were class D. A more even distribution was noted in TransAtlantic Inter-Society Consensus II classification for femoral and popliteal disease. Seventeen percent of patients had one-vessel infrageniculate runoff. In 21 limbs (54%), external iliac artery (EIA) stenting was performed at the time of procedure, 18 (46%) had common iliac artery (CIA) stenting, and 7 (18%) had a bridging stent from the CIA to EIA. The modal EIA stent diameter was 10 mm (range, 8-10 mm), modal CIA stent diameter 8 mm (range, 7-9 mm). The preintervention ankle-brachial index was 0.45 ± 0.24 (n = 33 limbs) and significantly improved to 0.75 ± 0.27 (n = 29 limbs; P < .001). In addition, preintervention toe pressure of 34 ± 28 (n = 28 limbs) improved to 58 ± 26 (n = 23 limbs; P < .001). No intraoperative complications occurred, which necessitated abdominal or retroperitoneal exposure. Average follow-up after the intervention was 13 ± 14.6 months. One limb (3%) required an additional outflow bypass. The incidence of ipsilateral hypogastric occlusion increased from 35% to 55% postoperatively; however, no patients reported pelvic or buttock ischemia. One patient who had the procedure done bilaterally presented 655 days after the procedure with bilateral iliac artery thrombosis and underwent aortobifemoral bypass. No other patient needed subsequent primary assisted patency or additional infrainguinal revascularization.
  
  
  CONCLUSIONS
  Hybrid-based external iliac and femoral endarterectomy provides a minimally invasive approach to EIA occlusive disease comparable with aortofemoral bypass. Dramatic inflow improvement was observed in our series, and the need for additional outflow revascularization was minimal. The procedure was deemed technically feasible and safe, with a low number of adverse sequela and excellent primary patency achieved more than 1 year after the intervention.
authors.affiliation: Department of Surgery, St. Joseph Mercy Health Center, Ann Arbor, Mich.
authors.forename: Crystal M
authors.initials: CM
authors.lastname: Kavanagh
authors.affiliation: Department of Surgery, St. Joseph Mercy Health Center, Ann Arbor, Mich.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Heidenreich
authors.affiliation: Department of Surgery, St. Joseph Mercy Health Center, Ann Arbor, Mich.
authors.forename: Jeremy J
authors.initials: JJ
authors.lastname: Albright
authors.affiliation: Department of Surgery, St. Joseph Mercy Health Center, Ann Arbor, Mich. Electronic address: abdulhameed_aziz@ihacares.com.
authors.forename: Abdulhameed
authors.initials: A
authors.lastname: Aziz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D055109:Ankle Brachial Index; D003131:Combined Modality Therapy; D000072226:Computed Tomography Angiography; D004691:Endarterectomy / Q000009:adverse effects; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation; D005240:Feasibility Studies; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008824:Michigan; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency