Long-Term Results of Treatment of Aortoiliac Occlusive Disease With the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique: A UK Multicenter Study.

Objective: This updated UK multicenter study aims to report long-term results following use of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique for treating aortoiliac occlusive disease (AIOD) in patients with chronic limb-threatening ischemia (CLTI) or intermittent claudication (IC).

Methods: A retrospective analysis was conducted including 85 patients who underwent CERAB between November 1, 2012, and March 31, 2020, till March 2024. Anatomical data were assessed using pre-operative imaging. Outcome measures included freedom from target lesion reintervention (fTLR), freedom from major limb amputation (fMLA), and overall survival.

Results: The median age was 65 years, with 62.4% males. Over a median follow-up of 58.2 months (IQR 55.7-67.1 months), 2 patients were lost to follow-up. There were 16 deaths (18.8%) and 2 major amputations (2.4%) in the entire study period. Target lesion reintervention was required in 14 patients (16.5%) at the last follow-up. The Kaplan-Meier fTLR at 1, 3, and 5 years was 89.2%, 83.0%, and 83.0%, respectively. fMLA at 1, 3, and 5 years was 98% at all intervals, and survival rates at 1, 3, and 5 years were 94.1%, 89.4%, and 80.1%, respectively. Subintimal iliac access was associated with worse fTLR (HR 4.33 (95% CI 1.30-14.37, p=0.017)), which remained significant when adjusted to patient and anatomical characteristics (HR 5.88 (95% CI 1.02-33.95, p=0.047)). There was no significant association between fTLR and the need for common femoral endarterectomy (HR 3.57 (95% CI 0.42-30.5, p=0.244)] or external iliac artery stenting (HR 0.47 (95% CI 0.07-3.05, p=0.427)) during the index procedure.

Conclusion: The long-term outcomes of CERAB for treating AIOD demonstrate its viability as a durable revascularization option, with acceptable morbidity, mortality, and patency rates. Factors reflecting more complex lesions are associated with poorer outcomes. Findings support the need for randomized controlled trials on CERAB and a focus on the pre- and intra-operative decision-making based on the complexity of TASC C and D lesions.

Clinical impact: The findings of this study reinforce the long-term durability of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique for treating aortoiliac occlusive disease (AIOD), demonstrating favourable reintervention and limb salvage rates. These results support CERAB as a viable alternative to open surgery, particularly in patients with complex anatomies or significant comorbidities. This data enables clinicians to make more informed decisions regarding patient selection and procedural strategies, such as minimising the use of subintimal iliac access to improve long-term outcomes. The study underscores the need for further randomised trials to establish CERAB's role in evidence-based clinical guidelines for AIOD management.