IYSC11 - Long-term results after anatomical reconstruction of aortic bifurcation with bifurcated unibody stent-grafts in aorto-iliac obstructive disease

Objectives: Endovascular revascularization of aorto-iliac lesions is particularly challenging in cases of complex and extensive obstructions. In selected patients, the off-label use of a unibody bifurcated stent-graft, such as the Endologix AFX, has become a tailored strategy for treating complex disease involving the aortic bifurcation. This study aimed to evaluate the feasibility and safety of this strategy for obstructive aorto-iliac lesions with aortic bifurcation involvement.

Methods: Over an eight-year period (2016-2024), all patients who underwent endovascular or hybrid revascularization for aorto-iliac occlusive disease were screened. From a total of 377 cases, 35 (9.3%) patients were selected for this study. These patients received aorto-iliac revascularization for obstructive lesions using the AFX Unibody stent-graft. Anatomical and clinical characteristics were classified according to TASC II stages and Rutherford categories. Demographic, preoperative, intraoperative, and postoperative data were collected in a dedicated database, adhering to SVS reporting standards. Early outcomes were assessed based on 30-day rates of thrombosis, major amputation, and mortality. Follow-up outcomes were evaluated using life-table analysis (Kaplan-Meier curves) to determine 5-year primary and secondary patency, freedom from reintervention, amputation-free survival, and overall survival. Group comparisons were performed using the log-rank test. All p-values were two-sided, and a p-value < 0.05 was considered statistically significant.

Results: The mean age was 64.8 ± 9.3 years (range 43–83). All 35 patients were treated with the AFX Unibody stent-graft, with adjunctive stenting required in 32 cases (91.4%). Technical success, on an intention-to-treat basis, was achieved in all patients. The mean Ankle-Brachial Index (ABI) improved by 0.45 (from 0.41 preoperatively to 0.86 postoperatively). The overall complication rate was 17.1%: two patients (5.7%) developed postoperative pneumonia, and four (11.4%) required surgical reintervention—three for access-site complications and one for aortic thrombosis. Patency of the target arterial segment was successfully restored in all cases. The mean in-hospital length of stay was 6.8 ± 3.2 days, with no early mortality. At 30 days, one thrombosis (2.9%) and one major amputation (2.9%) were recorded. Estimated 5-year overall survival was 69.8%. Primary and secondary patency rates were 78% and 93.3%, respectively. Estimated 5-year limb salvage and freedom from reintervention were 87.1% and 85.4%, respectively.

Conclusions: In this experience, the AFX Unibody stent-graft demonstrated safety and efficacy in the anatomical treatment of obstructive lesions involving the aortic bifurcation, particularly in younger patients with multilevel arterial disease. This cohort may benefit from a tailored anatomical reconstruction of the aortic bifurcation, as it facilitates potential subsequent "up-and-over" procedures.