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Risk Factors For Failure Of Iliac Stents In The Treatment Of Occlusive Disease
Jocelyn Beach, MD1, Abdul Aziz Zien El-Abeden Mohamed, MB, BCh, MS2, James Bena, MS1, Rebecca L. Kelso, MD1, Sean P. Lyden, MD1, Daniel G. Clair, MD3.
1Cleveland Clinic, Cleveland, OH, USA, 2Beni-Suef University, Beni Suef, Egypt, 3University of South Carolina, Columbia, SC, USA.

Objective Endovascular intervention for iliac occlusive disease is the primary technique for the treatment of aortoiliac occlusive disease. Compared to open intervention, this less invasive option is associated with an increased risk of failure. Our objective was to identify patient and procedural risk factors associated with failure of iliac stents in the treatment of iliac occlusive disease.
Methods From 2007 to 2012, 331 iliac arteries in 212 patients underwent stenting to treat iliac occlusive disease. Primary endpoint was stent failure, defined as occlusion or significant stenosis, on duplex or angiography. Technical success was defined as < 30% stenosis of target vessel without major intraprocedural complication. Kaplan-Meier estimates of failure-free survival were calculated, and changes in the risk of failure were described using univariable and multivariable Cox proportional hazards models.
Results
Of the 331 iliac limbs treated, 194 (58.6%) were TASC C or D lesions. Seventy-three (22%) treated limbs experienced failure, 29 were early, within the first month. Overall patency was 78.6% and 74.6% at 1 and 2 years, respectively. Univariable comparisons note that patients with a younger age, current smoking status, critical limb ischemia, occluded external iliac artery, need for common femoral endarterectomies, or without initial technical success were at greater risk of stent failure (p<0.05). This risk of stent failure was 3.0 times higher in current smokers. Limbs without initial technical success were 6.3 times more likely to fail, and were more likely to fail early. Patients with early failure tended to be younger, smokers, have critical limb ischemia, or more severe external and internal iliac disease (p<0.05, Figure 1). In a multivariable model for overall stent failure, critical limb ischemia and lack of technical success remain significant (p<0.05).
Conclusions
Endovascular interventions for iliac occlusive disease are highly successful, if early failure is avoided. This risk is highest in young smokers with more severe iliofemoral disease, critical limb ischemia, and initial technical failure. Patient disease burden cannot be modified, however ensuring an adequate initial angiographic result and smoking cessation are integral to the success of iliac interventions.


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