Long-term outcomes of covered versus bare metal stents in the reconstruction of the aortic bifurcation

Summary: Background: To report long-term outcomes following stenting for aortoiliac occlusive disease, focusing on covered stents (CS) versus bare metal stents (BMS) in a real-world, multicentre European cohort. Design: Multicentre retrospective cohort study. Patients and methods: Prospectively maintained data from nine European vascular centres (2012–2020) were analysed. Two cohorts were evaluated: aortic-only stenting and aortoiliac stenting (stratified as CS/CS, CS/BMS, BMS/CS, and BMS/BMS). Primary outcomes were target lesion revascularisation (TLR), major amputation, and mortality, with median follow-up of 75 months. Cox regression and propensity score matching were performed to adjust for baseline anatomical and procedural differences between stent types. Results: A total of 201 patients were included (50% male, mean age 65 years, 34% with chronic limb-threatening ischaemia). In the aortic-only subgroup (n = 46), outcomes were comparable between CS and BMS. Among aortoiliac reconstructions (n = 155), patients treated with CS/CS had greater anatomical complexity, including higher prevalence of iliac chronic total occlusions, longer lesions, and heavier calcification. Independent predictors of TLR included iliac chronic total occlusion, subintimal aortic recanalization, and concomitant common femoral endarterectomy. After propensity score adjustment, there remained no significant difference in TLR (28/155), major amputation (4/155), or mortality (30/155) between CS/CS and BMS/BMS groups. Conclusions: CS was preferentially employed in more complex aortoiliac occlusive disease and achieved outcomes equivalent to BMS after adjustment for lesion severity using propensity score methods. These findings reinforce that operator selection patterns and lesion complexity, rather than stent type alone, influence the clinical outcomes, underscoring the need for individualised stent selection strategies in advanced aortoiliac disease.