Discussion

Dr George Andros (Encino, Calif). I would like to congratulate you not only for presenting a wonderful series but also for coming to us with 10-year clinical and hemodynamic data. That is something we must encourage from our colleagues who favor endovascular techniques and I applaud you for doing that.

I have two questions. In view of the fact that 20% of your patients developed contralateral occlusive disease after they had an aorto or iliofemoral bypass, would you recommend that the patients with extensive unilateral iliac disease undergo primary aortobifemoral bypass and thereby solve the problem once and forever?

Second, since the patients with compromised outflow on the recipient side did less well, would you recommend that they are watched more closely with a low threshold for receiving a distal bypass graft? Not only would this policy relieve symptoms but also preserve the cross femoral bypass.

Dr Jean-Baptiste Ricco. Concerning your first question and looking at the results of our study, you may be right, however, at the present time, we will certainly proceed first with an iliac recanalization or a hybrid procedure with iliac recanalization and femoral reconstruction. If this does not work, we will then certainly consider a bilateral revascularization particularly if the life expectancy of the patient is high. Concerning the femoral outflow, occlusion or significant stenosis of the SFA in the recipient leg was associated in our study with a significantly lower patency after crossover bypass but not after direct bypass, and we will certainly recommend in these cases a distal revascularization to enhance patency of the crossover bypass.

Dr Vikram Kashyap (Cleveland, Ohio). Two questions. One, in our series, looking at endovascular recanalization of iliac occlusions, 30% of groin vessels needed either an endarterectomy or a profundaplasty. Is that similar in your series?

Second, when this study started 20 years ago, all of these patients were excluded from endovascular techniques that were deemed not feasible. But in the end, if I understood correctly, approximately 16% ended up getting an angioplasty on the ipsilateral iliac artery. Have endovascular techniques changed your approach to iliac occlusions?

Dr Jean-Baptiste Ricco. Concerning your first question, we have the same experience, in this series, 52 out of 143 patients (36%) had a profundaplasty with or without a femoral endarterectory. Considering your second question, we did 12 angioplasties of the donor iliac artery in the crossover group mainly for TASC A or B lesions that developed some years after construction of the crossover bypass. In the direct bypass group, 14 patients (20.2%) developed significant stenosis of the contralateral iliac artery requiring angioplasty in six and crossover bypass in two. Our practice has certainly changed in the last 10 years. Not surprisingly, endovascular techniques can provide excellent long-term results in selected iliac artery lesions and have also improved the outcome of crossover femoral bypass in patients with suboptimal donor iliac artery.

Dr Subodh Arora (Washington, DC). I noticed that quite a number of patients in the iliofemoral group, you used the transperitoneal approach. Was there any particular reason why that approach was used over the retroperitoneal?

Dr Jean-Baptiste Ricco. Two different techniques were used in the direct bypass group: 36 patients had an aortofemoral bypass and 33 patients had a common iliac-femoral bypass. Forty-three patients had a retroperitoneal approach and 26 patients had a transperitoneal approach. All direct iliofemoral bypasses and 10 aortofemoral bypasses were approached by a retroperitoneal route. Transperitoneal route was used exclusively in the remaining 26 patients with an aortafemoral bypass. In this study, the choice of the operative technique was left to the discretion of the surgeon.