Bifurcated Endografts for the Treatment of Aortoiliac Disease a Systematic Review and Individual Patient Data (IPD) Meta-Analysis

Background: This review aimed to assess the efficacy and safety of bifurcated endografts in the treatment of aortoiliac disease (AOID). Methods: A systematic search on PubMed, Scopus, and Web of Science was performed. The primary endpoint was primary patency, whereas secondary endpoints included reintervention, technical, clinical success, and overall postoperative complications. Results: Ten studies with a total of 365 patients were included in this review. Most included studies used the AFX unibody endograft, one study the Excluder endograft, and one the Powerlink endograft. The majority of included patients displayed TransAtlantic InterSociety Consensus (TASC) D aortoiliac lesions (56.1% 205/365). The pooled primary patency estimates at 12, 24, and 36 months were 93.93% (95% confidence interval [CI]: 87.7–100), 91.46% (95% CI: 84.6–98.8), and 90.25% (95% CI: 82.6–98.6), respectively. The mean primary patency time was 85.74 months (95% CI: 71.99–86.88). The pooled freedom from reintervention estimates at 12, 24, and 36 months were 91.94% (95% CI: 81.4–100), 91.03% (95% CI: 79.8–100), and 91.03% (95% CI: 79.8–100), respectively. The pooled estimates of major complications (rupture, graft thrombosis, amputation) were 11.12% (95% CI, 0.05%–3.03%), 3.76% (0.32%–9.45%), and 0.38% (0%–2.59%), whereas the pooled estimates for minor complications (hematoma, groin infection, dissection) and overall mortality were 5.27% (95% CI, 1.11%–11.38%), 6.93% (95% CI, 2.94%–12.16%), 2.19% (95% CI, 0.06%–6.14%), and1.57% (95% CI, 0.13–3.97), respectively. Technical and clinical success estimates were 99.92% (95% CI: 98.86%–100%) and 99.47% (95% CI: 94.92%–100%), respectively. Conclusion: The application of bifurcated endografts may present a safe and viable option in the treatment of AOID, with preliminary results indicating promising primary patency outcomes. However, the definitive assessment of their efficacy and safety will be better determined through long-term follow-up studies and high-quality randomized controlled trials, which are essential to substantiate these initial findings. Clinical Impact Bifurcated endograft application may be a safe and viable alternative for high-risk patients with complex AOID TASC C and D lesions with encouraging primary patency outcomes potentially comparable to those of open surgery. Non-negligible postoperative complication rates were also noted. High-quality randomized controlled trials and studies comparing CERAB, kissing stenting, and the use bifurcated endografts for the treatment of AOID is necessary to draw more definite conclusions.