Eversion Endarterectomy – An Alternative Approach to Occlusive External Iliac Artery disease

Published:December 21, 2021DOI:


      • Single-centre retrospective study of eversion endarterectomy for TASC-II C-D EIA lesions.
      • Five-year primary and primary-assisted patency rates were 74% and 92%, respectively.
      • More durable patency than endovascular approaches and fewer complications than open bypass.
      • Eversion endarterectomy is a safe and effective technique for occlusive EIA disease.


      While endovascular intervention is the recommended first option for management of common iliac artery (CIA) lesions, it lacks durable patency for Trans-Atlantic Inter-Society Consensus (TASC)-II C and D lesions involving the external iliac artery (EIA). Aorto-femoral bypass is a durable option but is unsuitable in patients with significant co-morbidities. Eversion endarterectomy provides an alternative to both endovascular and extensive open aortoiliac reconstruction for occlusive EIA disease.

      Materials and Methods

      A single-center, retrospective review (2000–2020) of all patients undergoing eversion endarterectomy for EIA disease was undertaken. Demographic, clinical, operative and follow-up data were recorded.


      Fifty eversion endarterectomies were performed in 47 patients. The median age was 65.0 years (range 46–82) and 66.6% were male. Sixty-eight percent (n = 34) were ASA grade 3. Indications for intervention were disabling claudication (44%) and critical limb ischaemia (56%). Angiography demonstrated 22 TASC C and 28 TASC D lesions. The median follow-up was 18.5 months (range 0–149). The technical success rate was 100%, and 84% (n = 42) experienced an immediate symptomatic improvement. Primary and primary-assisted patency at one, three and five years was 86%, 82% and 74%, and 100%, 96% and 92%, respectively. The five-year limb salvage rate was 96%. Eight limbs required reintervention to maintain patency, either by open (n = 2), endovascular (n = 3) or hybrid approach (n = 3). Thirty-day mortality was 2% (n = 1) with 10% (n = 5) experiencing a procedure-related morbidity. All-cause mortality was 38% (n = 19) during the follow-up period.


      Eversion endarterectomy is a safe, effective alternative treatment for occlusive EIA disease. This study reports durable patency at five years and low perioperative morbidity and mortality.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Vitale GF
        • Inahara T.
        Extraperitoneal endarterectomy for iliofemoral occlusive disease.
        J Vasc Surg. 1990; 12 (discussion 14-5): 409-413
        • Inahara T.
        Endarterectomy for occlusive disease of the aortoiliac and common femoral arteries. Evaluation of results of the eversion technic endarterectomy.
        Am J Surg. 1972; 124: 235-243
        • Inahara T.
        The surgical treatment of aortoiliac atherosclerosis.
        Surgery. 1965; 58: 960-968
        • Norgren L
        • Hiatt WR
        • Dormandy JA
        • et al.
        Inter-society consensus for the management of peripheral arterial disease (TASC II).
        J Vasc Surg. 2007; 45: S5-67
        • Jongkind V
        • Akkersdijk GJ
        • Yeung KK
        • et al.
        A systematic review of endovascular treatment of extensive aortoiliac occlusive disease.
        J Vasc Surg. 2010; 52: 1376-1383
        • Mwipatayi BP
        • Sharma S
        • Daneshmand A
        • et al.
        Durability of the balloon-expandable covered versus bare-metal stents in the Covered versus Balloon Expandable Stent Trial (COBEST) for the treatment of aortoiliac occlusive disease.
        J Vasc Surg. 2016; 64: 83-94 e1
        • de Donato G
        • Bosiers M
        • Setacci F
        • et al.
        24-month data from the BRAVISSIMO: a large-scale prospective registry on iliac stenting for TASC A & B and TASC C & D Lesions.
        Ann Vasc Surg. 2015; 29: 738-750
        • Clair DG
        • Beach JM.
        Strategies for managing aortoiliac occlusions: access, treatment and outcomes.
        Expert Rev Cardiovasc Ther. 2015; 13: 551-563
        • Timaran CH
        • Prault TL
        • Stevens SL
        • et al.
        Iliac artery stenting versus surgical reconstruction for TASC (TransAtlantic Inter-Society Consensus) type B and type C iliac lesions.
        J Vasc Surg. 2003; 38: 272-278
        • Timaran CH
        • Stevens SL
        • Freeman MB
        • et al.
        External iliac and common iliac artery angioplasty and stenting in men and women.
        J Vasc Surg. 2001; 34: 440-446
        • Powell RJ
        • Fillinger M
        • Walsh DB
        • et al.
        Predicting outcome of angioplasty and selective stenting of multisegment iliac artery occlusive disease.
        J Vasc Surg. 2000; 32: 564-569
        • Revuelta Suero S
        • Martinez Lopez I
        • Hernando Rydings M
        • et al.
        Endovascular treatment of external iliac artery occlusive disease: midterm results.
        J Endovasc Ther. 2014; 21: 223-229
        • Premaratne S
        • Newman J
        • Hobbs S
        • et al.
        Meta-analysis of direct surgical versus endovascular revascularization for aortoiliac occlusive disease.
        J Vasc Surg. 2020; 72: 726-737
        • Indes JE
        • Pfaff MJ
        • Farrokhyar F
        • et al.
        Clinical outcomes of 5358 patients undergoing direct open bypass or endovascular treatment for aortoiliac occlusive disease: a systematic review and meta-analysis.
        J Endovasc Ther. 2013; 20: 443-455
        • Rinckenbach S
        • Guelle N
        • Lillaz J
        • et al.
        Femorofemoral bypass as an alternative to a direct aortic approach in daily practice: appraisal of its current indications and midterm results.
        Ann Vasc Surg. 2012; 26: 359-364
        • Martin D
        • Katz SG.
        Axillofemoral bypass for aortoiliac occlusive disease.
        Am J Surg. 2000; 180: 100-103
        • von Elm E
        • Altman DG
        • Egger M
        • et al.
        The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Ann Intern Med. 2007; 147: 573-577
        • Rutherford RB
        • Baker JD
        • Ernst C
        • et al.
        Recommended standards for reports dealing with lower extremity ischemia: revised version.
        J Vasc Surg. 1997; 26: 517-538
        • Donohoe CL
        • Dowdall JF
        • McDonnell CO
        • et al.
        Eversion endarterectomy for external iliac artery occlusive disease.
        Vasc Endovascular Surg. 2011; 45: 46-50
        • Committee TS
        • Jaff MR
        • White CJ
        • et al.
        An update on methods for revascularization and expansion of the tasc lesion classification to include below-the-knee arteries: a supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II).
        Vasc Med. 2015; 20: 465-478
        • Aboyans V
        • Ricco JB
        • Bartelink MEL
        • et al.
        2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS).
        Eur Heart J. 2018; 39: 763-816
        • Chiu KW
        • Davies RS
        • Nightingale PG
        • et al.
        Review of direct anatomical open surgical management of atherosclerotic aorto-iliac occlusive disease.
        Eur J Vasc Endovasc Surg. 2010; 39: 460-471
        • Capoccia L
        • Riambau V
        • da Rocha M.
        Is femorofemoral crossover bypass an option in claudication?.
        Ann Vasc Surg. 2010; 24: 828-832
        • Passman MA
        • Taylor LM
        • Moneta GL
        • et al.
        Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease.
        J Vasc Surg. 1996; 23 (discussion 9-71): 263-269
        • Ricco JB
        • Probst H
        French University Surgeons A. Long-term results of a multicenter randomized study on direct versus crossover bypass for unilateral iliac artery occlusive disease.
        J Vasc Surg. 2008; 47 (discussion -4): 45-53
        • Bekken JA
        • de Boer SW
        • van der Sluijs R
        • et al.
        Remote iliac artery endarterectomy: a case series and systematic review.
        J Endovasc Ther. 2018; 25: 140-149
        • Uhl C
        • Betz T
        • Pfister K
        • et al.
        Remote iliac artery endarterectomy with selective stent use at the proximal dissection zone in TransAtlantic Inter-Society Consensus C and D lesions.
        J Vasc Surg. 2019; 69: 1143-1149
        • Naylor AR
        • Ah-See AK
        • Engeset J.
        Aortoiliac endarterectomy: an 11-year review.
        Br J Surg. 1990; 77: 190-193
        • Kronick MD
        • Saiyed N
        • Norris M
        • et al.
        Eversion femoral endarterectomy for iliofemoral occlusive disease: a description of technique and series of cases.
        Ann Vasc Surg. 2018; 50: 106-111
        • Sitrangulo Junior C
        • Langer B
        • Kauffman P
        • et al.
        Arterial reconstruction of the iliofemoral segment by eversion endarterectomy.
        Rev Hosp Clin Fac Med Sao Paulo. 1991; 46: 63-73
        • Cs Nagy G
        • Wunsch M
        • Jordan A
        • Lange K
        Antegrade eversion endarterectomy of the external iliac artery.
        Eur J Vasc Endovasc Surg. 2013; 46: 103-109