Combined Percutaneous Transluminal Angioplasty and Extraanatomic Bypass For Symptomatic Unilateral Iliac Artery Occlusion With Contralateral Iliac Artery Stenosis Philip J. Walker, FRACS, John P. Harris, MS, FRACS, FRCS, FACS, DDU, James May, MS, FRACS, FACS, Sydney, Australia

We have reviewed our experience with percutaneous transluminal angioplasty of contralateral iliac stenosis and extraanatomic bypass of the occluded iliac artery. Twenty-two men and nine women with a mean age of 65 years (range 46 to 84) presented with symptomatic iliac occlusive disease. Twenty-four (77%) had disabling claudication, four (13%) rest pain, and three (10%) ischemic tissue loss. Six (19%) had undergone previous vascular reconstructive procedures. All had an occluded iliac artery on the symptomatic side and greater than 50% stenosis of the contralateral iliac artery. Percutaneous transluminal angioplasty of the iliac stenosis was done prior to extraanatomic bypass, using polytetrafluoroethylene. There were six late deaths after discharge. The only significant complication was a femoral artery thrombosis which was corrected when the bypass graft was performed. Cumulative primary graft patency was 89% at one year and 81% at three years. The crossover graft occluded in six patients, five within 48 months of surgery, and one after nine years. One of these occluded grafts was salvaged by thrombectomy, for a secondary patency rate of 85% at three years. Two patients required aortobifemoral bypass, one an iliobifemoral bypass and one an ilioprofunda bypass. One patient operated upon for rest pain came to below-knee amputation. Mean resting ankle/brachial systolic pressure index increased significantly on the side of the lilac occlusion from 0.35 +0.21 to 0.70 _+ 0.20 (p < 0.05, paired t test) after the combined procedure. There was no significant difference in the mean resting ankle/brachial systolic pressure index on the contralateral side (0.60 _+0.22 to 0.65 • 0.27, ns). Combined iliac percutaneous transluminal angioplasty and femorofemoral bypass is a safe alternative to aortobifemoral bypass for selected patients with aortoiliac arterial occlusive disease. (Ann Vasc Surg 1991 ;5:209-217). KEY WORDS: Iliac artery; iliac occlusion; contralateral iliac stenosis; percutaneous transluminal angioplasty; extraanatomic bypass.

From the Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, Australia. Presented at the Royal Australasian College of Surgeons, General Scientific Meeting, May 1989, Melbourne, Australia. Reprint requests: John P. Harris, Department of Surgery, Blackburn Building, University of Sydney, Sydney, NSW 2006, Australia.

Symptomatic occlusive disease of the iliac arteries was originally managed by aortoiliac and aortofemoral bypass or endarterectomy. The significant morbidity and mortality of these procedures, particularly for the high risk patient, led to a search for alternative procedures. These alternatives now include extraanatomic bypass, (usually femorofemoral) and percutaneous transluminal angioplasty (PTA).

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and femorofemoral bypass in their experience of PTA as an adjunct to the surgical management of peripheral vascular disease [14]. Our retrospective study was undertaken to determine the results of combined percutaneous transluminal angioplasty and femorofemoral bypass for symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis.

MATERIALS AND METHODS Between 1980 and 1988, 31 patients with symptomatic occlusive disease of the iliac arteries were treated by combined PTA and femorofemoral bypass at Royal Prince Alfred Hospital, Sydney, Australia. Patients were considered for this combined procedure at the discretion of the treating vascular surgeon, if preoperative arteriography showed iliac artery occlusion on the symptomatic side and a contralateral iliac artery stenosis causing greater than 50% diameter reduction. During this same period, 90 patients had aortobifemoral or aortobiiliac grafts for occlusive iliac artery disease, and 164 Fig. 1. Translumbar aortogram of a 55-year-old man with left thigh claudication, showing occlusion of left common iliac artery and stenosis of right common iliac artery (arrow).

Femorofemoral bypass, introduced by Freeman and Leeds in 1952 [1] and popularized by Vetto in 1962 [2], has a low perioperative morbidity and five year cumulative patency rate~ ranging from 73 to 83% [3-9]. This procedure is usually indicated for unilateral iliac artery occlusion, without significant stenosis of the contralateral iliac artery. Percutaneous catheter dilatation of arterial stenoses was first described by Dotter and Judkins in 1964 [10]. Their results with coaxial catheter dilatation were discouraging. The introduction of a balloon catheter technique by Gruntzig in 1974 [i1] rekindled interest in PTA. The results of peripheral arterial PTA are influenced by the size of the artery treated. Five year cumulative patency rates approaching 90% have been reported for PTA of iliac lesions, far better than that achieved in the superficial femoral artery (SFA) [12]. Long segmental occlusions of the iliac artery are generally not suitable for treatment by PTA. A patient with symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis (Fig. 1) Cannot be managed by PTA of femorofemoral bypass alone. In 1973, Porter reported successful limb salvage achieved by combining the procedures and dilating the iliac stenosis prior to femorofemoral bypass [13]. K a d i r and associates included 12 patients treated by combined iliac PTA

Fig. 2. Aortogram in same patient after percutaneous transluminal angioplasty of right iliac stenosis with an 8 m m balloon, and extraanatomic bypass from right external iliac artery to left external lilac artery using an 8 mm polytetrafluoroethylene graft.

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patients had femorofemoral bypass grafts without a TABLE I.--Complications of combined percutaneous transluminal angioplasty and extraanatomic preceding iliac artery dilatation. bypass in 31 patients Twenty-two men and nine women underwent combined iliac artery PTA and femorofemoral Complications Number crossover. They had a mean age of 65 years (range Percutaneous transluminal angioplasty Femoral arterial thrombosis 46 to 84 years). All had been smokers, with 22 (71%) Groin hematoma still smoking up to the time of admission. Eleven Extraanatomic bypass (36%) of the 31 patients had known ischemic heart Atelectasis disease, eight having had previous myocardial infVenous thromboembolism Superficial wound infection arctions, two suffering with angina pectoris and one Bleeding peptic ulcer with ischemic cardiomyopathy and complete heart Late graft thrombosis block requiring ventricular pacing. Thirteen of the patients (42%) were on medication for control of hypertension. Five (16%) had known cerebrovascular disease, three with previous strokes and two RESULTS with transient iscfiemic attacks. Two (6%) were diabetic and one (3%) had hyperlipidemia. Twenty-four (77%) of the 31 patients complained of intermittent claudication severe enough to PTA and surgery threaten their employment or limit essential daily activities, four (13%) experienced rest pain, and All patients had an iliac artery occlusion on the three (10%) had ischemic ulceration. symptomatic side and a contralateral iliac stenosis Six patients (19%) had undergone previous vasof greater than 50%. The iliac occlusion was on the cular reconstructive surgery on the symptomatic left in 24 (77%) patients and on the right in the limb. In the remaining 25 patients (81%), iliac PTA remaining seven (23%) patients. The superficial and femorofemoral bypass were performed as a femoral artery was patent on the side of iliac primary procedure. occlusion in 17 (55%) of the 31 patients and patent When noninvasive arterial studies were peron the side of lilac stenosis in 17 (55%) Patients also. formed, Doppler arterial waveforms were recorded Pressure gradients were measured in only four and segmental systolic pressure were measured (13%) patients. In those four patients, pre-PTA before and after treadmill exercise (10% grade, 2 pressure gradients of 22, 3, 10 and 30 mmHg were km/h) to calculate ankle/brachial systolic pressure reduced to 0, 0, 0 and 8 mmHg, respectively, indices (ASPI). All 31 patients included in this following PTA. A single stenosis was dilated in 23 series had preoperative arteriography that showed (74%) patients and the remaining eight (26%) paan iliac artery occlusion on the symptomatic side tients had serial iliac stenoses dilated. Stenosis of and a contralateral iliac artery stenosis causing the common iliac artery was the most frequently greater than 50% diameter reduction. Percutaneous transluminal angioplasty of the iliac encountered (56%), followed by the external iliac stenosis was performed during the initial diagnostic artery (38%). The most significant complication arteriography in four cases and as a separate pro- after PTA was thrombosis of the femoral artery, cedure in 27 patients. Anticoagulation was not which occurred at the site of catheter insertion in used. Femorofemoral bypass, using polytetrafluo- one patient (Table I). This was corrected at the time roethylene (PTFE) as graft material, was performed of extraanatomic bypass. Twenty-four (77%) of the extraanatomic bypass at a mean interval of four days (range 0 to 29 days, grafts were femorofemoral, five (16%) were iliofemmedian 2 days) after PTA. oral, and two (7%) were ilioilial. Complications are Perioperative morbidity and mortality were defined as events occurring within 30 days of opera- listed in Table I. There was no incidence of early tion. The mean follow-up period was 45 months graft thrombosis or graft sepsis. There was no mortality within 30 days of surgery. (range 1 to 119 months, median 36 months). A graft was considered patent if a pulse was palpable over There were six late deaths during a mean follow-up the graft or at both femoral arteries. Hemodynamic period of 45 months (range I to 119 months, median success was defined as improvement in postopera- 36 months), giving a late mortality for the group of tive ASPI greater than 0.15 [15]. Primary patency 19%. Two of the deaths were due to pneumonia and was based on patency to first graft occlusion or respiratory failure at two months and seven intervention to prevent graft occlusion. Cumulative months. The other four late deaths were due to patency was determined by the modified life table myocardial infarction at two, three, six and eight method [16-18]. years, respectively.

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tion ultimately failed in only one of the 3 ! patients. Overall, repeat PTA was performed in four (13%) of the 31 patients. These all had single, focal iliac stenoses on their original arteriography. No unique features were identified that could predict recurrence after PTA.

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Fig. 3. Primary and secondary cumulative graft patency after combined percutaneous and extraanatomic bypass. Patency

Primary cumulative patency was 89% at one year and 81% at three years (Fig. 3). The secondary cumulative patency rate was 85% at three years. There was no statistically significant difference shown in cumulative graft patency at three years between subgroups based on the indication for surgery (claudication 82%, limb salvage 80%), patency of the recipient limb SFA (patent 86%, occluded 75%), or whether PTA and extraanatomic bypass was a primary or secondary procedure (primary 81%, secondary 83%). There were six late graft occlusions, despite further PTA of the iliac artery in three of these patients. Five of these occlusions occurred within two years of surgery. One graft was salvaged by successful thrombectomy. Another patient, who initially presented with rest pain, required belowknee amputation. Two patients underwent aortobifemoral bypass, another had an iliobifemoral bypass. The final patient, whose graft failed after nine years, required an ilioprofunda bypass. He had previously undergone repeat iliac PTA, and bilateral femorodistal bypass. Three other patients have required additional intervention. One patient required repeat iliac PTA on two occasions. This patient also required femorodistal bypass on the side of the stenotic iliac artery on two occasions, saphenous vein patching of a stenotic segment in one of these grafts, a lumbar sympathetic nerve block, and amputation of three toes on the donor side. The other two patients required femorodistal bypass on the side of the stenotic iliac artery. With this additional intervention, revasculariza-

Hemodynamic evaluation was obtained in 25 of the 31 patients, eight of whom also had exercise studies prior to PTA and following surgery (Table II). In the symptomatic limb, the mean resting ASPI on the side of iliac occlusion increased from 0.35 + 0.21 prior to intervention to 0.70 + 0.20 after combined PTA and surgery (p < 0.05, paired t test). The increase was greatest in the 13 patients in whom the SFA was patent. There were five hemodynamic failures (increase in ASPI < 0.15). The extraanatomic bypass graft occluded in three of these five patients. In the limb on the side of the iliac stenosis, categorized as the donor limb with respect to the extraanatomic bypass, there was no significant change in mean resting ASPI (0.60 + 0.22 to 0.65 -+ 0.27, ns). Nor was the difference significant in the subgroups with patent and occluded SFA. Although no patient was symptomatic, a slight decrease in ASPI in the donor limb occurred in 11 of the 25 patients tested, suggesting a minor hemodynamic "steal". The SFA was occluded in seven of these 11 patients, three of whom required further surgery, two for crossover graft occlusion. Of the eight patients who had pre- and postprocedure exercise studies available for evaluation, three showed an impaired pressure response to exercise on the donor side, following the combined procedure. These patients were not symptomatic.

DISCUSSION Combined PTA and extraanatomic bypass for symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis is a safe procedure. In this series of 31 patients there was no perioperative mortality and few serious complications. All patients initially had symptomatic relief from their ischemic symptoms although four (13%) required repeat PTA, and nine (29%) patients required further surgical intervention. Only one patient, originally presenting with rest pain, required amputation when his bypass graft occluded. The morbidity of PTA was also low in this series, with the only serious complication being thrombosis of the femoral artery in one patient, which was corrected at the time of extraanatomic bypass grafting. The asymmetrical distribution of iliac arterial

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TABLE II.lHemodynamic measurements before and after percutaneous transluminal angioplasty and extraanatomic bypass

Recipient limb Resting SFA~ patent SFA occluded Subtotal Post-exercise SFA patent SFA occluded Subtotal Donor limb Resting SFA patent SFA occluded Subtotal Post-exercise SFA patent SFA occluded Subtotal

Limb No.

Mean ASP|* pre-PTA t

Mean ASPI post-surgery

p value

13 12 25

0.47 • 0.11 0.21 + 0.21 0,35 + 0.21

0.85 _+ 0.09 0.53 _+ 0.14 0.70 _+ 0.20