Currently, thromboendarterectomy, ABFB, and
endovascular intervention options are available in the
treatment of aortoiliac occlusive disease.[
3]
Control of DM, antiplatelet and statin therapy,
antihypertensive therapy, quitting smoking and
exercise play an important role in medical treatment. It
has been reported that cilostazol, a phosphodiesterase
III inhibitor, reduces claudication complaints and may
be beneficial in providing graft patency and preventing
restenosis.[4]
The five-year patency rates of aortoiliac bypass
grafting vary between 80 and 95.10% and between
75 and 80% annually. The Dacron and PTFE bypass
surgeries performed in aortic and iliac vessels with
large calibration and high flow patterns have excellent
long-term results.[5] Randomized multi-center studies
have shown no significant difference between the
five-year patency rates between both grafts.[6]
Arterial autologous grafts are the best choice for
revascularization. However, this option for coronary
arteries is not available for aorta, iliac, and distal
arterial structures. Endovascular interventions have
been increasingly used, particularly in peripheral
infrainguinal lesions.[7] Currently, endovascular
interventions are often preferred to surgery in
low-calibrated vascular structures. Endovascular
approach has become more preferred, particularly
when comorbid diseases and advanced age pose a
risk. The results of bypass with artificial grafts in
distal peripheral vascular diseases are not satisfactory.
Therefore, many vascular surgeons today have adopted
endovascular atherectomy, balloon, or stent procedure
for more peripheral lesions.
Aortoiliac occlusive disease is often considered as
Leriche syndrome. The lesions are classified as Type
A, Type B, Type C, and Type D by the TASC.[8] In
recent years, widespread stent-balloon applications
have been applied to TASC-C and TASC-D lesions.
However, the long-term results are still unclear.
Although recent studies indicate a patency rate of 60 to
86%, based on all studies, five-year patency rates do not
exceed 80%.[9-11] These results indicate that aortoiliac
bypass grafting is still the best revascularization option for TASC-C and TASC-D lesions. In our
study, the bypass procedure was successfully applied
to all patients. In another study comparing the
results of endovascular stenting and bypass grafting
in aortoiliac lesions, the authors recommended iliac
artery stenting, particularly in elderly and those having
severe comorbidities, since the patency rates were
lower than surgical treatment.[12] Since the study
includes Type B lesions, it can be also considered that
the surgical option remains up-to-date in all aortic
and iliac lesions. In addition, since unilateral and
bilateral lesions were not distributed homogeneously
in the study, we consider that stent-balloon results
were exaggerated. In laparoscopic vascular surgery, the
disadvantages of this technique are the long operation
time and insufficient aortic exposure, the inability
to place a safe cross-clamp, the use of expensive
disposable instruments, excessive aortic calcification,
previous abdominal operations and obesity.
Since bypass surgery is mostly performed with
artificial grafts, there is a risk of infection, thrombosis,
and aneurysm. Many laboratory and clinical studies
have been conducted showing that PTFE graft is
more resistant to infection.[13] In our study, we did not
observe such complications in any of the patients. One
of our patients died from SIRS within a few hours
after the operation; however, it was not related to a
complication of infection.
It is very rare to encounter major complications
while open ABFB surgery. Immediate complications
in this surgery are vascular damage, bleeding,
intestinal damage, ileus, myocardial infarction, and
renal failure. Late complications are aorto-enteric
fistula, sexual dysfunction, infection, graft thrombosis
and anastomotic pseudoaneurysms.[14]
Postoperatively, we reoperated one of our
patients for bleeding. However, we could not find
the bleeding focus, and 0.25 mg protamine sulfate
was administered systemically. The heterogeneous
nature of unfractionated heparin, polydispersity of
molecular weight or different chemical properties may
cause different responses in patients. Therefore, ACT
monitoring is required in routine operations. Heparin
has advantages due to its short half-life, its ability to
be monitored with activated partial thromboplastin
time, and to be completely neutralized with protamine
sulphate. Since heparin has a short half-life and
we follow bleeding drainage, we did not perform
postoperative ACT control routinely.
Cross-clamp time is important in surgical vascular
interventions. Insufficient blood supply to the distal
arterial vessels can always cause serious ischemic
events. It can cause limb loss or amputation. Acute
spinal cord ischemia after ABFB has been reported
in the literature.[15,16] In vascular surgery, keeping
the ischemia time as short as heparinization time
can prevent unpredictable ischemic complications.
In our study, the mean operation and cross-clamp
time are consistent with the literature. The bypass
option is always more advantageous in terms of cost,
compared to endovascular treatment. Routine use of
the retroperitoneal approach cannot be recommended
for standard aortoiliac occlusive disease, although it is
advantageous in certain situations. It makes it difficult
to tunnel the graft, particularly in patients with obesity.
The main limitations of the present study are the
lack of a large sample size and inability to compare
the results with endovascular treatment. Further,
multi-center, large-scale studies are needed to compare
open surgical results with endovascular treatment. In
particular, the small sample size of the study limits the
generalizability of findings or the ability to provide
detailed clinical results.
In conclusion, endovascular interventions are
currently performed more commonly than bypass
surgery in the treatment of aortoiliac occlusive disease.
However, the surgical success and patency rates with
Y graft are still higher in TASC-C and D lesions.
As a result, there is no second treatment option that
has achieved surgical treatment success in aortoiliac
occlusive, bilateral vascular diseases. Open surgical
treatment should be the preferred treatment due to
long-term patency rate for all patients, except for
elderly and those having severe comorbidities.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.