Comparative Evaluation of Endovascular Treatment Methods in Patients with Aortoiliac Lesions of Moderate and High Cardiovascular Perioperative Risk

Objective. Comparative evaluation of efficacy and safety of the kissing-stent technique and covered endovascular reconstruction of the aortic bifurcation (CERAB) in patients with aortoiliac lesions of moderate and high cardiovascular perioperative risk. Material and Methods. A total of 105 patients with hemodynamically significant aortoiliac atherosclerotic lesions of moderate and high cardiovascular perioperative risk were included in this ambispective cohort study. The Duke Activity Status Index (DASI) and the Gupta MICA scale (Gupta Perioperative Risk for Myocardial Infarction or Cardiac Arrest) were used to assess cardiovascular perioperative risk. III stage chronic lower limb ischemia according to Fontaine–Pokrovsky classification was observed in 84 patients (80.0%) and stage IV in 21 patients (20.0%). A total of 66 patients (62.9%) had infrarenal aortic occlusion. A total of 49 patients underwent CERAB, and 56 patients underwent kissing-stent treatment with bare-metal stents. The severity of calcification in the aortoiliac segment was assessed using the PACSS (Peripheral Arterial Calcium Scoring System) based on computed tomography data. Primary endpoint included primary patency. Secondary endpoint included technical success, operation time, intraoperative blood volume loss, adverse cardiovascular events (local and systemic complications, cardiovascular mortality) in the early postoperative period, intensive care unit (ICU) length of stay, hospital length of stay, long-term postoperative complications, secondary patency, freedom from amputation, and survival rate. Results. The median follow-up duration was 48.0 [interquartile range (IQR) 33.0; 54.0] months. The median operation time was 73.5 [IQR 60.0; 100.0] minutes in the CERAB group and 67.5 [IQR 45.0; 95.0] minutes in the kissing-stent group (p = 0.723). The median intraoperative blood volume loss was 80.5 [IQR 75.4; 110.0] mL in the CERAB group and 81.4 [IQR 68.2; 105.0] mL in the kissing-stent group (p = 0.865). Technical success was 98.0% in the CERAB group and 92.9% in the kissing-stent group (p = 0.369). The median ICU length of stay was 1.54 [IQR 1.0; 2.0] days in the CERAB group and 1.67 [IQR 1.0; 2.0] days in the kissing-stent group (p = 0.968). The median hospital length of stay was 5.0 [IQR 4.0; 7.0] days in the CERAB group and 6.4 [IQR 4.5; 7.8] days in the kissing-stent group (p = 0.744). In the early postoperative period, complications occurred in three patients (6.1%) from the CERAB group and in five patients (8.9%) from the kissing-stent group (p = 0.721). In the long-term postoperative period, complications occurred in one patient (2.0%) from the CERAB group and in two patients (3.6%) from the kissing-stent group (p = 1.000). Primary patency at 60 months was 85.1% in the CERAB group and 59.4% in the kissing-stent group (p = 0.047). Secondary patency at 60 months was 92.9% in the CERAB group and 91.3% in the kissing-stent group (p = 0.883). Freedom from amputation at 60 months was 95.4% in the CERAB group and 93.3% in the kissing-stent group (p = 0.985). Survival rate at 60 months was 95.7% in the CERAB group and 96.0% in the kissing-stent group (p = 0.772). Predictors of loss of primary patency of the aortoiliac segment after kissing stent included grade 3–4 calcification according to the PACSS, the presence of thrombotic masses in the lumen of the infrarenal aorta, and hemodynamically significant damage to the outflow arteries. Conclusions. The results of this study demonstrated the advantage of CERAB over kissing-stent technique in terms of five-year primary patency with comparable safety. The predictors of loss of primary patency after kissing-stent treatment identified in this study indicate the need for more careful patient selection and a personalised approach to treatment selection.