Total Cranial Vault Reconstruction for Hydrocephalic Macrocephaly Using Virtual Surgical Planning: Evaluation of Technique and Outcomes

Objective: To describe early and mid-term outcomes of Viabahn stenting for extensive aorto-iliac occlusive disease involving the external iliac artery. Methods: In this single center retrospective study, all consecutive patients in whom a covered self-expanding Viabahn stent was implanted (W.L Gore & Associates, Inc., Flagstaff, AZ–USA) in the external iliac artery for symptomatic TASC II C and D lesions between 2012 and 2020 were included. Lesions limited to the iliac artery were treated percutaneously. Iliac lesions extending down to the common femoral artery were treated with a hybrid approach. Patency, major adverse limb events, target lesion revascularization (TLR) and limb salvage rates were estimated using Kaplan-Meier curves. Results: Out of 118 limbs, 48 (41%) were treated for claudication, 33 (28%) for rest pain, and 37 (31%) for tissue loss. Lesions were TASC C (n = 43 limbs, 36%) or TASC D (n = 75 limbs, 64%). Chronic total iliac occlusions were identified in 26 limbs (22%). Concomitant common femoral artery lesions were recorded in 97 limbs (82%). All lesions involved the external iliac artery. Technical success was achieved in 100% of cases. Six (5.7%) perioperative major adverse cardiovascular events occurred, including 4 (3.8%) deaths. Eleven (7.6%) early major adverse limb events were recorded. Two-years primary patency, assisted primary patency and secondary patency were 85%, 88%, and 95%, respectively. After multivariate analysis, small-diameters stents (<8 mm) was associated with lower primary patency rates (HR 3.20, 95% CI 1.26-8.13, P = .014) and lower freedom from TLR rates (HR 2.61, 95% CI 1.02-6.66, P = .045). Adjunctive common femoral artery endarterectomy was significantly associated with higher primary patency rates (HR 0.38 95% CI 0.15-0.95, P = .038). Conclusion: The use of Viabahn self-expanding covered stents for extensive aorto-iliac disease involving the external iliac artery provided acceptable post-operative morbidity and high rates of mid-term secondary patency, similar to those usually reported with aortobifemoral bypass. Adjunctive common femoral artery endarterectomy was a major determinant of patency and should be considered an essential component of the treatment strategy. Additional long-term data are necessary to evaluate the role of self-expanding covered stents for the treatment of such lesions.