Addressing critical challenges: Aortoiliac occlusive disease management in Ethiopia

Introduction: Aortoiliac occlusive disease (AIOD), a type of peripheral artery disease (PAD), occurs due to atherosclerotic blockage of the lower abdominal aorta and iliac arteries, resulting in reduced blood flow to the pelvic region and lower extremities. Management options include endovascular interventions and open surgical reconstruction, with the latter being the gold standard in advanced cases. In low- and middle-income countries (LMICs) like Ethiopia, open surgery remains the primary treatment due to limited access to endovascular techniques. This study aims to evaluate the safety and effectiveness of open aortoiliac surgery for AIOD in Ethiopia, providing insights into the feasibility of these procedures in similar resource-limited settings. Methodology: This retrospective case series was conducted at a single major referral center in Ethiopia, evaluating 36 consecutive patients with chronic atherosclerotic aortoiliac occlusive disease (AIOD) who underwent open surgery between January 2018 and May 2023. Data were collected from medical records, operation logbooks, and follow-up interviews. Key variables, including demographics, clinical profiles, diagnostic tests, operative records, and postoperative outcomes, were analysed using SPSS version 25.0, with categorical and continuous variables summarized using appropriate statistical methods. Result: A total of 36 patients underwent open surgical reconstruction for aortoiliac occlusive disease (AIOD) between January 2018 and May 2023. The majority were male (63.9%), with a mean age of 61.1 years. Ischemic tissue loss was the most common presentation (69.4%), and 63.9% of patients had TASC D lesions. Post-operatively, 91.7% of patients experienced symptom resolution. Early complications occurred in 41.7% of cases, including surgical site infections (25%) and pneumonia (11.1%). The early mortality rate was 2.8%, and 11.1% of patients required limb amputation. Late graft occlusion occurred in five patients, and three patients died during follow-up. Discussion: Open surgical reconstruction proves effective for AIOD management in resource-limited settings like Ethiopia, where endovascular options are scarce. Symptomatic relief in 91.7% of patients shows the feasibility of open surgery, despite severe disease and high comorbidities. However, the high incidence of early postoperative complications, such as surgical site infections and limb amputations, points to the severe disease at presentation and the challenges of managing such patients in a resource-limited environment. The study also emphasizes the importance of improvements in surgical training, access to materials, and the formal establishment of vascular surgery programs, which have contributed to an increased number of successful surgeries over time. Conclusion & Recommendation: Open surgical reconstruction for AIOD in Ethiopia shows promise in symptom relief and limb salvage, even with limited resources and no established endovascular alternatives. Despite progress, high early complications like infections and graft occlusion highlight the challenges of managing advanced cases in this setting. Early diagnosis using ABI and duplex ultrasound, better pre-op care for comorbid patients, and public health efforts to reduce risk factors like hypertension and smoking are essential. Expanding training, introducing endovascular techniques, and structured long-term follow-up are key to improving outcomes. Further research is needed to refine AIOD management in similar contexts.