Long-term Results of Endovascular Therapy for Extensive Aortoiliac Occlusive Disease (EAIOD) and Key Risk Factors for Treatment Success

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Long-term Results of Endovascular Therapy for Extensive Aortoiliac Occlusive Disease (EAIOD) and Key Risk Factors for Treatment Success

If you or someone you know has faced severe leg pain, fatigue, or even open ulcers from blocked arteries in the abdomen and hips, you’re not alone. Extensive aortoiliac occlusive disease (EAIOD)—a condition where the main arteries supplying blood to the legs (the aorta and iliac arteries) are severely narrowed or blocked—has traditionally required major open surgery. But new research from Fudan University’s Zhongshan Hospital and Jinshan Hospital in Shanghai suggests a less invasive option, endovascular therapy, works surprisingly well even for the most complex cases. The study also identifies three key factors that determine whether the treatment will stay effective long-term.

What Is Extensive Aortoiliac Occlusive Disease (EAIOD)?

EAIOD affects the aorta (the body’s largest artery, running from the heart to the pelvis) and the iliac arteries (which branch off the aorta to supply blood to the legs). When these arteries become blocked by plaque (fatty buildup), blood flow to the legs drops—causing symptoms like:

  • Intermittent claudication: Pain or cramping in the buttocks, hips, or thighs when walking.
  • Critical limb ischemia (CLI): Severe pain at rest, open ulcers, or gangrene (tissue death) from lack of blood flow.

Doctors classify EAIOD using the TASC II system, where “C” and “D” lesions are the most complex—meaning long, multiple, or completely blocked segments. Until recently, these cases were almost always treated with aortobifemoral bypass (open surgery to replace the blocked arteries with a graft). But this surgery carries risks like infection, bleeding, and long recovery times.

The Study: Evaluating Endovascular Therapy for Complex EAIOD

A team of vascular surgeons led by Xiao-Lang Jiang, Yun Shi, and Zhi-Hui Dong at Fudan University wanted to see how well endovascular therapy (minimally invasive procedures using catheters and stents) works for TASC II C/D lesions. They reviewed data from 148 patients treated between 2008 and 2018, tracking:

  • Technical success: Did the procedure successfully open the blocked arteries?
  • Primary patency: Did the treated arteries stay open without needing additional procedures?
  • Survival rates: How many patients were alive 5–10 years later?
  • Risk factors: Which patient or disease traits led to treatment failure (loss of primary patency)?

Most patients had TASC II D lesions (60.8%), the most complex type. Surgeons used techniques like:

  • Transfemoral/transbrachial access: Inserting catheters through the groin or arm to reach the blocked arteries.
  • Kissing stents: A specialized procedure to rebuild the aortic bifurcation (where the aorta splits into iliac arteries) by placing two stents that “kiss” at the split.
  • Hybrid procedures: Combining minimally invasive stenting with small incisions (e.g., to clear blocked femoral arteries).

Key Results: Endovascular Therapy Works for Complex EAIOD

The study found strong long-term outcomes for endovascular therapy:

  • Technical success: 88.5% of procedures successfully opened the blocked arteries.
  • Patency rates:
    • 82.1% of patients had primary patency (open arteries without reintervention) at 5 years.
    • 74.8% had primary patency at 10 years.
  • Survival: 84.2% of patients were alive 5 years after treatment.
  • Recovery: Median hospital stay was just 8 days, with minimal blood loss (15 mL on average—less than a tablespoon).

These results are comparable to open surgery but with fewer complications. Only 15.8% of patients had perioperative (around the time of surgery) issues like artery dissection or infection—far lower than the 17–32% complication rate for open bypass.

Three Major Risk Factors for Losing Primary Patency

While endovascular therapy worked well overall, three factors made it more likely that the treated arteries would reclose (lose primary patency):

1. Age Under 61 Years

Younger patients (under 61) were 6.5 times more likely to lose primary patency than those over 70. Why? Atherosclerosis (plaque buildup) in younger adults is often more aggressive—progressing faster and affecting more blood vessels. The study found 30.6% of patients under 61 needed additional procedures to keep their arteries open, compared to 10.2–15.9% of older patients.

2. Critical Limb Ischemia (CLI)

Patients with CLI (rest pain, ulcers, or gangrene) were 7.8 times more likely to lose primary patency. CLI signals severe, advanced disease with poor collateral blood flow (small blood vessels that normally compensate for blocked arteries). These patients have more extensive plaque buildup, making it harder to keep arteries open long-term.

3. Smoking

Current smokers were 10 times more likely to lose primary patency than non-smokers. Smoking damages blood vessels by:

  • Damaging the inner lining of arteries (endothelium).
  • Increasing inflammation and plaque buildup.
  • Reducing blood flow to already blocked arteries.

Nearly half (48.9%) of the study’s patients were smokers, and none quit after surgery. Among those who lost primary patency, 76.9% were active smokers—highlighting how critical smoking cessation is for long-term success.

Why This Matters for Patients and Doctors

For years, TASC II guidelines recommended open surgery for C/D lesions. But this study adds to growing evidence that endovascular therapy is a safe, effective alternative—especially for patients who can’t tolerate big surgery (e.g., those with heart or lung disease). Key takeaways:

  • Endovascular therapy is a viable first-line option for complex EAIOD, with similar long-term results to open surgery but fewer risks.
  • Watch for high-risk patients: Younger adults, smokers, and those with CLI need closer monitoring to prevent reblockage.
  • Smoking cessation is non-negotiable: Even if you’ve had a successful procedure, smoking will undo the benefits.

Limitations to Consider

Like all studies, this one has drawbacks:

  • Retrospective design: Data was collected from past medical records, so there may be biases in how patients were selected.
  • Varied surgeons: Procedures were done by multiple surgeons over 10 years, which could affect consistency.
  • Restenosis assessment: The team used ultrasound, CT scans, and ankle-brachial index (ABI) to check for reblockage—not gold-standard angiography.

Despite these limitations, the study provides real-world evidence that endovascular therapy works for EAIOD—a game-changer for patients who want to avoid open surgery.

Conclusion

Extensive aortoiliac occlusive disease doesn’t have to mean major surgery. This 10-year study from Fudan University shows that endovascular therapy is effective for even the most complex cases, with strong long-term patency and survival rates. The biggest takeaway? If you’re under 61, have CLI, or smoke, work closely with your doctor to monitor your arteries and reduce risk.

For patients, this means more options and less fear. For doctors, it means rethinking how we treat complex vascular disease—prioritizing minimally invasive care whenever possible.

Long-term results of extensive aortoiliac occlusive disease (EAIOD) treated by endovascular therapy and risk factors for loss of primary patency
Xiao-Lang Jiang, Yun Shi, Bin Chen, Jun-Hao Jiang, Tao Ma, Chang-Po Lin, Da-Qiao Guo, Xin Xu, Zhi-Hui Dong, Wei-Guo Fu
Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University; Center for Vascular Surgery and Wound Care, Jinshan Hospital, Fudan University, Shanghai 201508, China
Chinese Medical Journal 2021;134(8)

doi.org/10.1097/CM9.0000000000001229

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