What are the guidelines for aorto-iliac reconstruction?

Aorto-iliac Reconstruction CERAB

What is CERAB?

CERAB (Covered Endovascular Reconstruction of the Aortic Bifurcation) is an advanced endovascular technique for treating extensive aorto-iliac occlusive disease, particularly TASC II D lesions involving the infrarenal aorta and bilateral iliac arteries. This technique uses covered stents to reconstruct the aortic bifurcation percutaneously, offering a minimally invasive alternative to traditional aortobifemoral bypass surgery. 1

Guideline-Based Approach to Aorto-iliac Reconstruction

Primary Treatment Strategy

An endovascular-first strategy is now the recommended approach for aorto-iliac occlusive disease, with CERAB representing a viable option for complex TASC C and D lesions when traditional open surgery carries prohibitive risk. 1

• For short stenosis/occlusion (<5 cm) of iliac arteries, standard endovascular therapy achieves >90% patency over 5 years with low complication risk 1
• For extensive occlusions extending to the infrarenal aorta, covered endovascular reconstruction of the aortic bifurcation (CERAB) demonstrates 87% primary patency at 1 year and 82% at 2 years 1
• When occlusion extends from renal arteries through iliac arteries in fit patients, aortobifemoral bypass remains the gold standard with 5-year patency of 85.8% and 10-year patency of 79.4% 2

Patient Selection Algorithm

Choose CERAB over open surgery when:

• Patient has severe cardiopulmonary comorbidities making open surgery high-risk 1
• Extensive TASC D aorto-iliac occlusive disease is present with suitable anatomy for covered stent deployment 1
• Previous abdominal surgery or hostile abdomen increases open surgical risk 3
• Patient requires at least 2 cm landing zones proximally and distally for stent-graft fixation 4

Choose open aortobifemoral bypass when:

• Patient is fit for surgery with acceptable operative risk 1
• Patient cannot comply with mandatory long-term endovascular surveillance imaging 1
• Anatomy is unsuitable for endovascular approach (inadequate landing zones, severe calcification preventing stent deployment) 5
• Life expectancy exceeds 10 years and durability is paramount 2

Critical Technical Considerations for CERAB

The procedure requires bilateral femoral access with covered stent-grafts deployed in a "kissing stent" configuration to reconstruct the aortic bifurcation. 1

• Ensure adequate proximal landing zone of ≥2 cm in infrarenal aorta below renal arteries for secure fixation 4
• Plan for distal landing zones extending into common femoral arteries if necessary 1
• Technical success rates for complex aorto-iliac endovascular reconstruction exceed 93% in experienced centers 6
• Consider hybrid procedures combining iliac stenting with femoral endarterectomy when disease extends to common femoral artery 1

Management of Combined Inflow and Outflow Disease

For patients with multilevel disease involving both aorto-iliac (inflow) and infrainguinal (outflow) segments, address inflow lesions first. 1

• Perform aorto-iliac reconstruction (CERAB or open) as the initial procedure 1
• If symptoms of critical limb ischemia or infection persist after inflow revascularization, proceed with outflow revascularization to tibial vessels 1
• Measure intra-arterial pressure gradients across suprainguinal lesions before and after vasodilator administration if hemodynamic significance is unclear 1

Perioperative Management

Initiate systemic anticoagulation immediately during the procedure to prevent thrombus propagation, and transition to indefinite antiplatelet therapy postoperatively. 2, 1

• All patients undergoing aorto-iliac revascularization require lifelong single antiplatelet therapy (aspirin 75-160 mg daily OR clopidogrel 75 mg daily) 5
• Consider dual pathway inhibition with rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily for high ischemic risk patients without high bleeding risk 5
• Mandate aggressive risk factor modification including smoking cessation, statin therapy, and blood pressure control 5

Surveillance Protocol

Patients undergoing CERAB require mandatory long-term surveillance imaging to monitor for endoleak, stent migration, and graft patency. 1

• Perform CT angiography or duplex ultrasound at 1 month, 6 months, 12 months, then annually 4
• Monitor for stent fracture, endoleak, and loss of patency requiring reintervention 1
• Document shrinkage or stability of any excluded aneurysmal segments 1

Comparative Outcomes: CERAB vs. Open Surgery

Short-term Outcomes

Endovascular CERAB demonstrates significantly lower perioperative systemic complications (6.7%) compared to open aortobifemoral bypass (40%), with no difference in technical complications. 3

• In-hospital mortality is comparable between approaches (0% in recent series) 3
• Overall complication rate is lower with endovascular approach (17.8% vs. 43.3%, OR 3.5) 3
• Hospital length of stay is shorter with endovascular techniques 3

Long-term Outcomes

Open aortobifemoral bypass achieves superior long-term primary patency (96.7% at 2 years) compared to endovascular reconstruction (80% at 2 years), but requires higher reintervention rates with endovascular approach (20% vs. 3.3%). 3

• 18-month primary patency for endovascular stented grafts is 89% with 100% secondary patency after reintervention 6
• Limb salvage rates at 24 months exceed 94% with both approaches 6
• Open surgery provides more durable results for younger patients with longer life expectancy 2

Common Pitfalls and How to Avoid Them

Avoid performing CERAB without adequate landing zones, as this leads to endoleak and early failure. 4

• Measure landing zones carefully on preoperative CT angiography—minimum 2 cm required 4
• Do not attempt CERAB in patients who cannot comply with surveillance imaging requirements 1
• Recognize that reintervention rates are higher with endovascular approaches, requiring patient counseling about this trade-off for lower initial morbidity 3
• Ensure patients understand that endovascular reconstruction requires lifelong surveillance, while open surgery typically does not 1

For patients with critical limb ischemia and multilevel disease, failing to address inflow disease first leads to poor outcomes and limb loss. 1

• Always assess and treat aorto-iliac disease before proceeding to infrainguinal bypass 1
• If uncertain about hemodynamic significance, measure pressure gradients with vasodilator challenge 1