This document compares outcomes of aortobifemoral bypass grafting (ABF) versus recanalization with percutaneous transluminal angioplasty and stenting (R/PTAS) for treating extensive aortoiliac occlusive disease. Patients who received ABF were younger on average and had higher rates of smoking and hyperlipidemia than the R/PTAS group. Both procedures showed high technical success rates and similar improvements in hemodynamic measures. Early follow-up data indicates ABF may provide better long-term patency rates compared to R/PTAS, though longer-term studies are still needed. The study aims to evaluate whether R/PTAS can provide a less invasive alternative to

1. REVASCULARIZAÇÃOREVASCULARIZAÇÃO
EM TERRITÓRIOEM TERRITÓRIO
AORTOILÍACOAORTOILÍACO
TRATAMENTO CIRÚRGICOTRATAMENTO CIRÚRGICO
ABERTOABERTO

2. INTRODUÇÃOINTRODUÇÃO
 1/3 PACIENTES COM ATEROSCLEROSE1/3 PACIENTES COM ATEROSCLEROSE
OBLITERANTEOBLITERANTE
 POPULAÇÃO – 39-65 ANOS 1-2%POPULAÇÃO – 39-65 ANOS 1-2%
ACIMA DOS 70 ANOS 6%ACIMA DOS 70 ANOS 6%
 SUCESSO INICIAL DE 96%SUCESSO INICIAL DE 96%
 PERVIEDADE - 5 ANOS – 91%PERVIEDADE - 5 ANOS – 91%
 MORBIDADE – 8,3%MORBIDADE – 8,3%
 MORTALIDADE – 3,3%MORTALIDADE – 3,3%

5. HISTÓRICOHISTÓRICO
 Sushuruta – Índia – 2500 AC – controle doSushuruta – Índia – 2500 AC – controle do
sangramentosangramento
 Hipócrates - bandagensHipócrates - bandagens
 Galeno – excisão – 15 séculos atrásGaleno – excisão – 15 séculos atrás
 Hallowel – 1759 – reconstrução vascularHallowel – 1759 – reconstrução vascular
 John Murphy – 1897John Murphy – 1897
 Alexis Carrel – Nobel 1912Alexis Carrel – Nobel 1912
 Dos Santos - EndarterectomiaDos Santos - Endarterectomia

6. HISTÓRICOHISTÓRICO
 DeBakey – 1953 – endarterectomia carotídeaDeBakey – 1953 – endarterectomia carotídea
 Arthur Voorhees – prótese vascularArthur Voorhees – prótese vascular
 Dotter – Angioplastia - 1964Dotter – Angioplastia - 1964
 Campos de Batalha – 1536 – Ambroise ParéCampos de Batalha – 1536 – Ambroise Paré
 2° Guerra – Walter Reed Army Hospital Group –2° Guerra – Walter Reed Army Hospital Group –
reparo no campo.reparo no campo.
 MASH – CoréiaMASH – Coréia

7. HISTÓRICOHISTÓRICO

9.  19231923
 CLAUDICAÇÃOCLAUDICAÇÃO
BILATERALBILATERAL
 AUSÊNCIA DE PULSOSAUSÊNCIA DE PULSOS
 IMPOTÊNCIAIMPOTÊNCIA

11.  1947 -1947 - TROMBOENDARTERECTOMIATROMBOENDARTERECTOMIA
 1952 - Wylie1952 - Wylie

12. ANATOMIAANATOMIA

17. TASC II Classification of Aortoiliac‐TASC II Classification of Aortoiliac‐
DiseaseDisease
Tipo ATipo A
 Estenose unilateral ou bilateral da artéria ilíacaEstenose unilateral ou bilateral da artéria ilíaca
comumcomum
 Estenose curta unilateral ou bilateral da artériaEstenose curta unilateral ou bilateral da artéria
ilíaca externa (<3cm)ilíaca externa (<3cm)

19. TASC II Classification of Aortoiliac‐TASC II Classification of Aortoiliac‐
DiseaseDisease
Tipo BTipo B
 Estenose curta aorta da infra-renal (<3cm)Estenose curta aorta da infra-renal (<3cm)
 Oclusão unilateral da artéria ilíaca comumOclusão unilateral da artéria ilíaca comum
 Uma ou várias estenoses - 3 10cm envolvendo‐Uma ou várias estenoses - 3 10cm envolvendo‐
a artéria ilíaca externa sem se extender para aa artéria ilíaca externa sem se extender para a
femoral comum.femoral comum.
 Oclusão unilateral da artéria ilíaca externa semOclusão unilateral da artéria ilíaca externa sem
envolver a origem da ilíaca interna ou femoralenvolver a origem da ilíaca interna ou femoral
comumcomum

22. TASC II Classification of Aortoiliac‐TASC II Classification of Aortoiliac‐
DiseaseDisease
Tipo CTipo C
 Oclusão da artéria ilíaca comum - bilateralOclusão da artéria ilíaca comum - bilateral
 Artéria Ilíaca Externa – bilateral - estenose - 3 10cm sem‐Artéria Ilíaca Externa – bilateral - estenose - 3 10cm sem‐
envolver a artéria femoral comumenvolver a artéria femoral comum
 Estenose unilateral da artéria ilíaca externa envolvendo a artériaEstenose unilateral da artéria ilíaca externa envolvendo a artéria
femoral comumfemoral comum
 Estenose unilateral da artéria ilíaca externa envolvendo a artériaEstenose unilateral da artéria ilíaca externa envolvendo a artéria
femoral comum e a origem da artéria ilíaca internafemoral comum e a origem da artéria ilíaca interna
 Oclusão unilateral da artéria ilíaca externa (calcificada) semOclusão unilateral da artéria ilíaca externa (calcificada) sem
envolver a artéria femoral comum e a origem da artéria ilíacaenvolver a artéria femoral comum e a origem da artéria ilíaca
internainterna

25. TASC II Classification of Aortoiliac‐TASC II Classification of Aortoiliac‐
DiseaseDisease
Tipo DTipo D
 Oclusão aórtica infra-renalOclusão aórtica infra-renal
 Doença difusa da aorta envolvendo ambas as ilíacasDoença difusa da aorta envolvendo ambas as ilíacas
 Múltiplas estenoses das artérias artéria ilíaca comum,Múltiplas estenoses das artérias artéria ilíaca comum,
interna e femoral comuminterna e femoral comum
 Oclusão unilateral da artéria da artéria ilíaca comum eOclusão unilateral da artéria da artéria ilíaca comum e
ilíaca externailíaca externa
 Oclusão bilateral da artéria ilíaca externaOclusão bilateral da artéria ilíaca externa
 Estenose ilíaca associada AAAEstenose ilíaca associada AAA

30. TÉCNICA OPERATÓRIATÉCNICA OPERATÓRIA

37. EndarterectomiaEndarterectomia
 Reservado para o Tipo IReservado para o Tipo I
 Não pode ser realizada em pacientes comNão pode ser realizada em pacientes com
AneurismaAneurisma
 PerviedadePerviedade
Cirurgião DependenteCirurgião Dependente
60 94% em 5 anos‐60 94% em 5 anos‐

39. Bypass AnatômicoBypass Anatômico
 AortofemoralAortofemoral
 Transabdominal ou RetroperitonealTransabdominal ou Retroperitoneal
 Anastomoses : Termino-terminal ou Termino-Anastomoses : Termino-terminal ou Termino-
laterallateral
 PTFE ou DacronPTFE ou Dacron

43. Bypass Extra-AnatômicoBypass Extra-Anatômico
 ABDÔMEN HOSTILABDÔMEN HOSTIL
 CONDIÇÕES CLÍNICASCONDIÇÕES CLÍNICAS
1.1. AXILO-FEMORALAXILO-FEMORAL
2.2. AXILO-BIFEMORALAXILO-BIFEMORAL
3.3. FEMORO-FEMORAL (CRUZADO)FEMORO-FEMORAL (CRUZADO)

45. INDICAÇÕES PARA OINDICAÇÕES PARA O
PROCEDIMENTO CIRÚRGICOPROCEDIMENTO CIRÚRGICO
 Recommendation 36Recommendation 36. Treatment of aortoiliac lesions. Treatment of aortoiliac lesions
· TASC A and D lesions: Endovascular therapy is the treatment of· TASC A and D lesions: Endovascular therapy is the treatment of
choice for type A lesions and surgery is the treatment of choicechoice for type A lesions and surgery is the treatment of choice
for type D lesions [C].for type D lesions [C].
· TASC B and C lesions: Endovascular treatment is the preferred· TASC B and C lesions: Endovascular treatment is the preferred
treatment for type B lesions and surgery is the preferredtreatment for type B lesions and surgery is the preferred
treatment for good-risk patients with type C lesions. Thetreatment for good-risk patients with type C lesions. The
patient’s co-morbidities, fully informed patient preference andpatient’s co-morbidities, fully informed patient preference and
the local operator’s long-term success rates must be consideredthe local operator’s long-term success rates must be considered
when making treatment recommendations for type B and type Cwhen making treatment recommendations for type B and type C
lesions [C].lesions [C].

46. BYPASS AORTOFEMORALBYPASS AORTOFEMORAL
 PERVIEDADEPERVIEDADE
5a perviedade % 10a perviedade %5a perviedade % 10a perviedade %
INDICAÇÃO CLAUDICAÇÃO ISQUÊMIA CRÍTICA CLAUDICAÇÃO ISQUÊMIA CRÍTICAINDICAÇÃO CLAUDICAÇÃO ISQUÊMIA CRÍTICA CLAUDICAÇÃO ISQUÊMIA CRÍTICA
MembrosMembros 91 (90 94)‐91 (90 94)‐ 87 (80 88)‐87 (80 88)‐ 86 (85 92)‐86 (85 92)‐ 81 (78‐81 (78‐
83)83)
Pacientes 85 (85 89)‐Pacientes 85 (85 89)‐ 80 (72 82)‐80 (72 82)‐ 79 (70 85)‐79 (70 85)‐ 72 (61‐72 (61‐
76)76)
de Vries S, Hunink M. Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-de Vries S, Hunink M. Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-
analysis. J Vasc Surg 1997;26(4):558-569.analysis. J Vasc Surg 1997;26(4):558-569.

47. Bypass ExtranatômicoBypass Extranatômico
 PERVIEDADEPERVIEDADE
Procedimento 5a perviedade %Procedimento 5a perviedade %
Axilo femoral bypassAxilo femoral bypass 51 (44 79)‐51 (44 79)‐
Axilo bi femoral bypassAxilo bi femoral bypass 71 (50 76)‐71 (50 76)‐
Femoral femoral bypassFemoral femoral bypass 75 (55 92)‐75 (55 92)‐

49. Objective:Objective: Aortobifemoral bypass (ABF) grafting has been the traditional treatment for extensive aortoiliac occlusiveAortobifemoral bypass (ABF) grafting has been the traditional treatment for extensive aortoiliac occlusive
disease (AIOD). This retrospective study compared the outcomes and durability of recanalization, percutaneousdisease (AIOD). This retrospective study compared the outcomes and durability of recanalization, percutaneous
transluminal angioplasty, and stenting (R/PTAS) vs ABF for severe AIOD.transluminal angioplasty, and stenting (R/PTAS) vs ABF for severe AIOD.
Methods:Methods: Between 1998 and 2004, 86 patients (161 limbs) underwent ABF (nBetween 1998 and 2004, 86 patients (161 limbs) underwent ABF (n __ 75) or iliofemoral bypass (n75) or iliofemoral bypass (n __ 11), and11), and
83 patients (127 limbs) underwent R/PTAS. All patients had severe symptomatic AIOD (claudication, 53%; rest pain,83 patients (127 limbs) underwent R/PTAS. All patients had severe symptomatic AIOD (claudication, 53%; rest pain,
28%; tissue loss, 12%; acute limb ischemia, 7%). The analyses excluded patients treated for aneurysms, extra-anatomic28%; tissue loss, 12%; acute limb ischemia, 7%). The analyses excluded patients treated for aneurysms, extra-anatomic
procedures, and endovascular treatment of iliac stenoses. Original angiographic imaging, medical records, andprocedures, and endovascular treatment of iliac stenoses. Original angiographic imaging, medical records, and
noninvasive testing were reviewed. Kaplan-Meier estimates for patency and survival were calculated and univariatenoninvasive testing were reviewed. Kaplan-Meier estimates for patency and survival were calculated and univariate
analyses performed. Mortality was verified by the Social Security database.analyses performed. Mortality was verified by the Social Security database.
Results:Results: The ABF patients were younger than the R/PTAS patients (60 vs 65 years;The ABF patients were younger than the R/PTAS patients (60 vs 65 years; PP __ .003) and had higher rates of.003) and had higher rates of
hyperlipidemia (hyperlipidemia (PP __ .009) and smoking (.009) and smoking (PP < .001). All other clinical variables, including cardiac status, diabetes,< .001). All other clinical variables, including cardiac status, diabetes,
symptoms at presentation, TransAtlantic Inter-Society Consensus stratification, and presence of poor outflow weresymptoms at presentation, TransAtlantic Inter-Society Consensus stratification, and presence of poor outflow were
similar between the two groups. Patients underwent ABF with general anesthesia (96%), often with concomitantsimilar between the two groups. Patients underwent ABF with general anesthesia (96%), often with concomitant
treatment of femoral or infrainguinal disease (61% endarterectomy, profundaplasty, or distal bypass). Technical successtreatment of femoral or infrainguinal disease (61% endarterectomy, profundaplasty, or distal bypass). Technical success
was universal, with marked improvement in ankle-brachial indices (0.48 to 0.84,was universal, with marked improvement in ankle-brachial indices (0.48 to 0.84, PP<.001). Patients underwent R/PTAS<.001). Patients underwent R/PTAS
with local anesthesia/sedation (78%), with a 96% technical success rate and similar hemodynamic improvement (0.36 towith local anesthesia/sedation (78%), with a 96% technical success rate and similar hemodynamic improvement (0.36 to
0.82,0.82, PP < .001). At the time of R/PTAS, 21% of patients underwent femoral endarterectomy/profundaplasty or bypass< .001). At the time of R/PTAS, 21% of patients underwent femoral endarterectomy/profundaplasty or bypass
(n(n __ 5) for concomitant infrainguinal disease.5) for concomitant infrainguinal disease. Limb-based primary patency at 3 years was significantly higher forLimb-based primary patency at 3 years was significantly higher for ABFABF
than for R/PTAS (93% vs 74%,than for R/PTAS (93% vs 74%, PP __ .002). Secondary patency rates (97% vs 95%), limb salvage (98% vs. 98%), and long-.002). Secondary patency rates (97% vs 95%), limb salvage (98% vs. 98%), and long-
term survival (80% vs 80%) were similar.term survival (80% vs 80%) were similar. Diabetes mellitus and the requirement of distal bypass were associatedDiabetes mellitus and the requirement of distal bypass were associated
with decreased patency (with decreased patency (PP < .001). Critical limb ischemia at presentation (tissue loss, hazard ratio [HR], 8.1;< .001). Critical limb ischemia at presentation (tissue loss, hazard ratio [HR], 8.1; PP < .< .
001), poor outflow (HR, 2;001), poor outflow (HR, 2; PP __ .023), and renal failure (HR, 2.5;.023), and renal failure (HR, 2.5; PP __ .02) were associated with decreased survival..02) were associated with decreased survival.
Conclusion:Conclusion: R/PTAS is a suitable, less invasive alternative to ABF for the treatment of severe AIOD. Repair of theR/PTAS is a suitable, less invasive alternative to ABF for the treatment of severe AIOD. Repair of the
concomitant femoral occlusive disease is often needed regardless of open or endovascular treatment. Infrainguinalconcomitant femoral occlusive disease is often needed regardless of open or endovascular treatment. Infrainguinal
disease negatively affects the durability of the procedure and patient survival. ( J Vasc Surg 2008;48:1451-57.)disease negatively affects the durability of the procedure and patient survival. ( J Vasc Surg 2008;48:1451-57.)

50. CONCLUSÃOCONCLUSÃO
 OPÇÃO DO TRATAMENTO CIRÚRGICOOPÇÃO DO TRATAMENTO CIRÚRGICO
 CONDIÇÕES ANATÔMICASCONDIÇÕES ANATÔMICAS
 CONDIÇÕES CLÍNICAS DO PACIENTECONDIÇÕES CLÍNICAS DO PACIENTE
 RISCO DO PROCEDIMENTORISCO DO PROCEDIMENTO
 INTERVENÇÕES PRÉVIASINTERVENÇÕES PRÉVIAS
 EXPECTATIVA DE VIDAEXPECTATIVA DE VIDA