Open Iliac Conduits Enabling the New Era of Endovascular Aortic Repair in Hostile Iliofemoral Anatomy: A Single-Center Retrospective Study

<i>Background and Objectives</i>: Hostile iliofemoral anatomy (HIA) challenges large-bore access in thoracic, branched, or fenestrated endovascular aortic repair (t/b/fEVAR). Retroperitoneal open iliac conduit (ROIC) enables safe delivery, but data in complex t/b/fEVAR are scarce. <i>Materials and Methods</i>: This retrospective single-center cohort study (2017-2025) of 80 t/b/fEVAR patients followed STROBE guidelines. Eight (10%) required elective ROIC for HIA (small iliac diameter < 7 mm or occlusive disease). Outcomes were compared to 23 no-conduit complex endovascular aortic repair cases. <i>Results</i>: ROIC patients [50% female, 87.5% smokers] had higher PAD [62.5% vs. 17.4%, <i>p</i>-value = 0.015]. All ROICs were elective [vs. 69.5% no-conduit, <i>p</i>-value = 0.076]; indications: Type V TAAA [50%], synchronous aneurysms (25%), Type II TAAA [12.5%] and arch aneurysm [12.5%]. Median operative time [365 vs. 200 min, <i>p</i>-value = 0.002], blood loss [1190 vs. 600 cc, <i>p</i>-value < 0.001], and contrast [420 vs. 300 cc, <i>p</i>-value = 0.004] were higher. Technical success was 100% [8/8] vs. 86.9% [20/23] (<i>p</i>-value = 0.28), and clinical success was 87.5% vs. 78.2% (<i>p</i>-value = 0.569). Median ICU stay [3 d vs. 2 d, <i>p</i>-value = 0.817] and hospital stay [12 d vs. 9 d, <i>p</i>-value = 0.404] were prolonged, albeit without statistically significant differences. In-hospital mortality was similar (12.5% vs. 17.4%, <i>p</i>-value = 0.746) between groups. One ROIC patient had intraoperative cardiac arrest [sheath dislodgement]; another required a covered stent for anastomotic rupture. At 12-month follow-up, one Type III endoleak required relining. <i>Conclusions</i>: Planned retroperitoneal open iliac conduits achieved 100% technical success in patients with hostile iliofemoral anatomy, without ischemic complications, despite longer operative times and higher blood loss. ROIC remains a safe and indispensable technique that extends complex endovascular aortic repair to otherwise ineligible patients.