The covered endovascular reconstruction of the aortic bifurcation (CERAB) represents nowadays an established technique for treating peripheral artery disease (PAD) with aorto-iliac lesions. The superiority of a CERAB reconstruction over covered or uncovered kissing stents due to more physiological hemodynamics has been demonstrated [1] and this is reflected by good early and midterm clinical results [2, 3]. However, there is little data so far regarding the endovascular treatment of the iliac artery bifurcation with a similar technique. Thus, the aim of this study was to evaluate the technique of covered endovascular reconstruction if the iliac artery bifurcation (CERIB) for PAD.

This was a restrospective single-center study including all patients who were treated by CERIB for PAD between January 2021 and January 2022. CERIB was performed as follows: First, covered stent implantation of the common iliac artery (CIA) was performed via an ipsilateral retrograde access, then the internal iliac artery (IIA) was cannulated in crossover-over technique (fig. 1) followed by stentgraft implantation into the IIA and into the external iliac artery (EIA) in kissing-technique (fig. 2). We analyzed demographical patient data, types of the implanted stentgrafts, frequency of endovascular and hybrid procedures, peri-/postoperative complications, operating and x-ray duration as well as patency and reintervention rates of the CERIB reconstruction during early follow-up (FU). FU information was obtained in the context of clinical routine controls.

12 patients were included (10 male, median age 69 years [60-76 years ]). The indications for operation were PAD stage IIb (n=10) and stage IV (n=1) according to the Fontaine classification, as well one case of endotension via the iliac limb of an aortic endoprosthesis. The lesions were stenoses in 6 patients, occlusions in 3 patients, a combination of stenosis and occlusion in 2 patients and a too narrow iliac artery bifurcation for iliac side branch implantation in the patient with endotension. The CERIB reconstruction was performed using Begraft peripheral stentgrafts (Bentley Innomed, Hechingen, Germany; CIA: n=5, EIA: n=12, IIA: n=13), BegraftAortic stentgrafts (Bentley Innomed, Hechingen, Germany; CIA: n=2, EIA: n=1) and one Begraft peripheral plus stentgraft (Bentley Innomed, Hechingen, Germany; CIA). 3 patients had preexisting stentgrafts in the CIA (2 aortic endoprosthesis limbs, 1 uncovered stent) and in one case an additional uncovered self-expanding stent had to be implanted as an extension into the EIA. Technical success was 100%. Additional procedures were rotational atherectomy of the iliac arteries in 2 patients for initial recanalization and 6 patients underwent a hybrid operation (uni-/bilateral femoral endarterectomy: n=5, open surgical access to the axillary artery: n=1). All other procedures were performed percutaneously via femoral approaches. 1 patient required perioperative blood transfusion, no other early complications were observed. The median operation duration was 2,8 (1,5-4,3) hours, the median x-ray duration was 28 (14-63) minutes. The median length of hospital stay was 7 (3-12) days and the median FU was 4 (1-13) months. The only complication during FU was 1 stentgraft occlusion in a patient with indication for CERIB due to stenosis at the end of a preexisting uncovered CIA stent. The occlusion was recurrent despite reintervention, so that open surgical revascularization was performed. There were no other reinterventions during FU. The in-hospital mortality was 0%, the overall mortality was 1/12 due cardiac arrest in a patient with preexisting congestive heart failure.

CERIB for the treatment of PAD of the iliac arteries is feasible percutaneously or in the context of a hybrid procedure with very low complication rates and good early patency. Thus, CERIB seems to be a promising technique for treating PAD of the iliac artery bifurcation, similarily to the early results of the now well established CERAB technique for the aortic bifurcation. However, further studies including larger patient cohorts and longer FU are required in order to draw final conclusions.

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