An endovascular first-strategy for obstructive aorto-iliac lesions is considered feasible if done by experienced team. The development of knowledges on how hemodynamic features influenced graft patency in diseased infrarenal aorta scenarios resulted in new technical strategies of endovascular approach as CERAB technique. The adoption of unimodular stent-grafts as AFX Unibody may be proposed in young selected cases with obstructive lesions of the infrarenal aorta associated with peripheral infrainguinal disease. Aim of this study is to evaluate the outcomes of endovascular procedures regarding TASC II C/D steno-obstructive lesions involving the infrarenal aorta and the aortic bifurcation, comparing the covered kissing stent (cKS), the covered reconstruction of aortic bifurcation (CERAB) and the AFX Unibody (UB).

The study is a comparative, observational, retrospective cohort study conducted in a single tertiary referral center. From January 2016 to January 2022 all patients underwent endovascular/hybrid aorto-iliac reconstruction with the above mentioned techniques for TASC II C-D lesions were identified. The obstructive involvement of the infrarenal aorta and/or the aortic bifurcation was observed in all the selected cases. Over the series of 102 patients, three groups were identified: cKS (46 cases, 45.2%), CERAB (31 cases, 30.3%) and UB (25 cases, 24.5%). All clinical and procedural data were prospectively collected and recorded. Immediate outcomes were: technical success (intention-to-treat analysis) and hemodynamical success (ABI, ankle-brachial index, improvement). Early results were analyzed in terms of 30-day thrombosis, amputation and death. Follow-up results were analyzed by life-table analyses (Kaplan-Meier curves) in terms of primary and secondary graft patency, freedom from reintervention, amputation free survival and overall survival. Groups were compared with log-rank test, all P-values were 2-sided and P<0.05 was considered significant. All the estimations were evaluated at 5 years of follow-up. Univariate Cox regression analysis was performed to identify risk factors associated with primary patency and survival.

Mean age was of 65.6 ± 9.7 years. Patients were affected by intermittens claudication and critical limb ischemia in 63 (61.8%) and 39 (38.2%) cases, respectively. Obstructive lesions were classified as TASC-II C in 20 (19.6%) and TASC-II D in 82 (80.4%) of the cases. Infrarenal aorta and aortic bifurcation were involved in 49 (48%) and 53 (52%) cases respectively, without any difference between the groups (p= .634). No differences were observed between the groups for Rutherford's clinical stage (p= .982) and TASC II (p= .432). Hybrid interventions (Common femoral artery endarterectomy with patch plasty) were performed in 30 (29.4%) cases followed by endovascular procedure and all the recanalizations were carried out in an antegrade fashion. Technical success was achieved in all the patients and hemodynamical success was assessed by a significant differences between pre- and post-operative ABI (0.39±0.16 vs 0.79±0.18; p= .001). No in-hospital deaths were observed. At 30-days two thromboses (1 [2.2%] cKS group and 1 [4%] UB group), two major amputations (1 [3.3%] CERAB group and 1 [4%] UB group) and one death (2.2% cKS group) were recorded. Mean age of follow-up was 23.3±18.5 months. Estimated overall primary patency was 70.5%. No thromboses were recorded in the CERAB group but data did not differ significantly between the groups (log-rank 3.2, p= .192). Estimated overall secondary patency was 89.3% and a slight difference was observed between the groups (log-rank 7.3, p= .025). This finding may be derived from reocclusions in UB group that did not underwent to reinterventions. Estimated overall limb salvage rate and freedom from reintervention were 98.8% and 71.1% and no significant differences were observed between the groups (limb salvage log-rank 1.1, p= .559, reintervention log-rank 1.5, p= .469). Estimated overall survival was 72% without differences between the groups (log-rank 1.3, p= .519). Univariate analysis did not find any factors affecting primary patency whereas overall survival is significantly affected by Rutherford's clinical stage (log-rank 11.7, p= .001).

The three strategies support the concept of an aortoiliac tailored revascularization. CERAB may represent the rational evolution of the covered kissing stent and unimodular bifurcated stent-graft could be useful in young patients to obtain an anatomical replacement of the aortic bifurcation and to overcome sizing limitations on the infrarenal aorta. In this experience none of the techniques has shown a superiority and these may be customized on each patients' characteristics and anatomies with safe and effective results.