LAUSR

OBJECTIVE To compare early and mid-term outcomes of polytetrafluoroethylene-covered stents (CS) versus bare-metal stents (BMS) used in the kissing conformation for the reconstruction of the aortic bifurcation in aorto-iliac obstructive disease. METHODS A multicenter cohort registry (2015-2019) collected 1306 patients receiving endovascular treatment for aorto-iliac arterial obstructive disease. Only patients receiving bilateral iliac kissing stents for TASC C-D lesions were included in the analysis. Thirty-day outcomes, mid-term primary patency, and limb salvage rates were compared between CSs and BMSs in matched cohorts of patients after propensity score modeling. Follow-up results were analyzed with Kaplan-Meier curves; Cox proportional hazards models were used to identify predictors of primary patency. RESULTS There were 336 patients treated with kissing stents, 201 (60%) CSs and 135 (40%) BMSs. In the unmatched cohort, patients receiving CSs were more likely to have critical limb ischemia (41% vs 30%; P=.038) and complex iliac lesions, as TASC D (90% vs 56%; P<.01), and iliac occlusions (59% vs 44%; P<.01). After propensity score-matching, 220 patients were selected (110 CSs and 110 BMSs), without differences in clinical presentation (critical limb ischemia, 41% vs 33%; P=.167), and anatomical complexity (TASC D, 66% vs 60%; P=.21. Iliac occlusion, 48% vs 49%; P=.89). Thirty-days mortality was 0%. The early medical (unmatched: 5% vs 4%; P=1.00. Matched: 5% vs 4%; P=.75) and surgical (unmatched: 5% vs 5%; P=1.00. matched: 5% vs 3%; P=.72) complication rates were similar between CSs and BMSs, but CSs had a lower risk of intraoperative iliac rupture (0% vs 3.5%; P=.013) and a greater ankle-brachial index improvement (0.43±0.22 vs 0.36±0.24; P=.02). At 36 months, overall primary patency (92±7% vs 92±8%; P=.38), secondary patency (98±3% vs 98±4%; P=.50), and limb salvage (93±9% vs 97±5%; P=.20) rates were similar. In case of moderate/severe iliac calcifications, CSs showed better results in the matched cohort (100% vs 89±9%; P=.048). At the multivariate analysis, CS use (HR 1.67; P=.45) did not significantly impact on primary patency, while older age (HR 0.93, P=.03) and kissing stents' diameter ≥8 mm (HR 0.25; P=.03) were significantly associated. CONCLUSION In this multicenter study, the use of kissing stents for the treatment of the aortic bifurcation provided good early and mid-term results. CSs were preferred for more complex lesions, were protective from iliac rupture, and allowed a greater ankle-brachial index improvement. Three-years patency rates were similar between CSs and BMSs, but CSs showed improved results in case of moderate/severe calcifications.