Int J Angiol Vol 18 No 3 Autumn 2009135
Operative management of multilevel iliofemoral
Sibu P Saha MD MBA FICA, Samantha M Terry PSE, Victor A Ferraris MD PhD FICA
Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky, USA
Correspondence: Dr Sibu P Saha, Division of Cardiothoracic Surgery, University of Kentucky, 900 Limestone Street, Suite 407, Lexington,
Kentucky 40536, USA. Telephone 859-257-8264, fax 859-278-4836, e-mail firstname.lastname@example.org
tion in the United States. Most patients with disabling symp-
toms have multilevel arterial occlusive disease. The
management strategies for patients with multilevel arterial
occlusive disease vary widely across the country. The decisions
are influenced by the experience of the surgeon. Verhagen and
van Vroonhoven (1) reported that most of these patients
could be treated by correcting the inflow occlusive disease
only. Porter et al (2) were the first to report a combined
approach for lower limb revascularization, which involved
iliac dilation and femorofemoral bypass for limb salvage. Since
then, numerous investigators (3-6) have reported the advan-
tages of this combined approach with short-term follow-up.
The current trend is to treat both inflow and outflow occlusive
disease by endovascular procedure either simultaneously or as
a staged procedure. The long-term benefits of the combined
approach are not available. The present study was undertaken
to investigate the risks and long-term benefits of a combined
one-stage approach by using endovascular techniques for iliac
occlusive disease and bypass for femoropopliteal occlusive
eripheral vascular disease is a manifestation of generalized
atherosclerosis; it affects 10% to 30% of the adult popula-
Over a 76-month period, 53 consecutive patients who under-
went combined iliac stenting and distal bypass were included
in the present study. The demographic and clinical characteris-
tics of the patients are shown in Table 1. These patients com-
prised 30 men and 23 women between 42 and 87 years of age.
Thirty-nine patients presented with disabling claudication,
nine with resting pain and five with tissue loss. Comorbidities
in these patients included coronary artery disease (n=28),
hypertension (n=36), diabetes mellitus (n=12), hyperlipidemia
(n=25) and tobacco use (n=40).
A total of 57 stents were implanted in 53 patients. Thirty-five
patients had a femoropopliteal bypass, 16 had a femorofemoral
bypass and two had a femoral distal bypass using an in situ
technique. There was one death in the present series of studies.
Complications included minor wound problems in nine
patients, atrial fibrillation in one patient, acute graft occlusion
in one patient and toe amputations in two patients. During a
six- to 96-month follow-up period, eight patients underwent
repeat distal bypass procedures, five patients underwent revas-
cularization on the contralateral sides and four patients under-
went repeat endovascular procedures.
©2010 Pulsus Group Inc. All rights reserved
SP Saha, SM Terry, VA Ferraris. Operative management of
multilevel iliofemoral occlusive disease. Int J Angiol
BAckgROUnD: The current trend is to treat both inflow and out-
flow occlusive disease using endovascular procedures either simulta-
neously or in a staged procedure. The long-term benefits of a combined
one-stage approach are not available.
OBJEcTIVES: The main objectives are to investigate the risks and
long-term benefits of a combined one-stage approach using endovas-
cular techniques for iliac occlusive disease and bypass for femoro-
popliteal occlusive disease.
METHODS AnD RESULTS: Fifty-three patients with limb ischemia
underwent combined ilial stenting and distal bypass. Complications
included minor wound problems in nine patients, atrial fibrillations in
one patient, acute graft occlusion in one patient, toe amputation in
two patients and one death. During a follow-up period of up to
96 months, eight patients required repeat distal bypass, five patients
underwent revascularization on contralateral sides and four patients
had repeat endovascular procedures.
cOncLUSIOn: These results suggest that there are few risks with a
combined endovascular procedure for iliac occlusion and bypass for
femoropopliteal occlusive disease. Long-term complications with the
combined approach included repeat distal bypass, revascularization on
contralateral sides and repeat endovascular procedure.
key Words: Endovascular procedure; Femoropopliteal bypass; Iliofemoral
Demographics and clinical characteristics of patients with
Age, years, range
Coronary artery disease
Data presented as n unless otherwise indicated
Saha et al
Int J Angiol Vol 18 No 3 Autumn 2009136
Data from the present investigation of a combined iliac
stenting and distal bypass procedure show that this procedure
had few complications (minor wound complications, n=9;
atrial fibrillation, n=1; occluded graft, n=1; and toe amputa-
tion, n=2). There was one death. During the follow-up period
(up to 96 months), there were four repeat endovascular proced-
ures, eight repeat bypass procedures and five revascularizations
on the contralateral sides.
Other investigators have used combined procedures. The
study of Griffith et al (7) included 25 patients with critical
limb ischemia. Eleven patients had combined procedures in
the operating room and 14 patients had angioplasty in the
radiology department followed by bypass in the operating
room. This study reported 8% mortality, 50% graft patency at
24 months follow-up and a limb salvage rate of 75%.
Numerous studies (8-12) have reported combined proced-
ures of angioplasty followed by stenting and bypass. Alimi et al
(13) reported that iliac transluminal angioplasty and distal
surgical revascularization could be performed as a one-step
technique in high-risk groups only. Melliere et al (14) reported
a 91% limb salvage rate at five years, and indicated multiple
advantages of single-step procedures, including low incidence
of infection, reduced costs, and avoidance of alteration of anti-
Our results are consistent with those of other investigators
(13-16). In selected groups of patients, this combined approach
of stenting and bypass has a high rate of success, a lower com-
plication rate, and very satisfactory short- and long-term
results. The current trend is to perform endovascular proced-
ures for both iliac and femoropopliteal occlusive disease. The
results of this approach should be compared with the combined
approach of iliac intervention and femoropopliteal bypass in a
prospective study for multilevel iliofemoral occlusive disease.
AcknOWLEDgEMEnT: The authors thank Dr Kailash Prasad
MBBS(Hons) MD PhD FRCPC FACC FICA FIACS for his invaluable
assistance in the preparation of this manuscript.
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