Aorto-iliac Reconstruction Guidelines

Introduction to CERAB

The European Society of Cardiology recommends CERAB as a viable option for complex TASC C and D lesions when traditional open surgery carries prohibitive risk, with 87% primary patency at 1 year and 82% at 2 years 1
CERAB demonstrates significantly lower perioperative systemic complications compared to open aortobifemoral bypass, with no difference in technical complications 1

The American College of Cardiology recommends an endovascular-first strategy for aorto-iliac occlusive disease, with CERAB representing a viable option for complex TASC C and D lesions when traditional open surgery carries prohibitive risk 1
For short stenosis/occlusion (<5 cm) of iliac arteries, standard endovascular therapy achieves >90% patency over 5 years with low complication risk 1
For extensive occlusions extending to the infrarenal aorta, covered endovascular reconstruction of the aortic bifurcation (CERAB) demonstrates 87% primary patency at 1 year and 82% at 2 years 1

The American College of Cardiology recommends choosing CERAB over open surgery when patient has severe cardiopulmonary comorbidities making open surgery high-risk, with extensive TASC D aorto-iliac occlusive disease present with suitable anatomy for covered stent deployment 1
Choose open aortobifemoral bypass when patient is fit for surgery with acceptable operative risk, with 5-year patency of 85.8% and 10-year patency of 79.4% 2
Patient requires at least 2 cm landing zones proximally and distally for stent-graft fixation, as recommended by the European Society of Cardiology 3

The European Society of Cardiology recommends ensuring adequate proximal landing zone of ≥2 cm in infrarenal aorta below renal arteries for secure fixation, with technical success rates for complex aorto-iliac endovascular reconstruction exceeding 93% in experienced centers 1
Plan for distal landing zones extending into common femoral arteries if necessary, as recommended by the American College of Cardiology 1

The American College of Cardiology recommends addressing inflow lesions first, with aorto-iliac reconstruction (CERAB or open) as the initial procedure, followed by outflow revascularization to tibial vessels if symptoms of critical limb ischemia or infection persist 7, 4
Measure intra-arterial pressure gradients across suprainguinal lesions before and after vasodilator administration if hemodynamic significance is unclear, as recommended by the American College of Cardiology 7

The American College of Cardiology recommends initiating systemic anticoagulation immediately during the procedure to prevent thrombus propagation, and transitioning to indefinite antiplatelet therapy postoperatively, with all patients undergoing aorto-iliac revascularization requiring lifelong single antiplatelet therapy 2, 4
Consider dual pathway inhibition with rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily for high ischemic risk patients without high bleeding risk, as recommended by the American College of Cardiology 6

The American College of Cardiology recommends mandatory long-term surveillance imaging to monitor for endoleak, stent migration, and graft patency, with CT angiography or duplex ultrasound at 1 month, 6 months, 12 months, then annually 5, 7
Monitor for stent fracture, endoleak, and loss of patency requiring reintervention, as recommended by the American College of Cardiology 5

Open aortobifemoral bypass achieves superior long-term primary patency (96.7% at 2 years) compared to endovascular reconstruction (80% at 2 years), but requires higher reintervention rates with endovascular approach (20% vs. 3.3%), as reported by the European Society of Cardiology 2