According to the TASC guidelines, patients with diffuse stenosis or occlusions, comprising TASC D lesions, are best suited to open surgical bypass. This procedure however requires general anesthesia, a laparotomy, and aortic cross clamping. Due to the extent of physiological insult with these maneuvers, mortality and systemic morbidity rates are substantial.

The weighted average of 30-day mortality was 2.4 % for ABF in studies published since 2000. A recent meta-analysis by Chiu, which spans four decades of data, reports 4 % mortality, 16 % systemic complications, and 6 % local complications in 5738 cases [7]. Dimick reported ABF procedures from the 1997 Nationwide Inpatient Sample, which is a 20 % sampling of 483 U.S. hospitals of various sizes and types. In-hospital mortality in this report was 3.3 % [8]. This number is the same as de Vrie’s reported mortality rate of 3.3 % in “recent” (post-1975) ABF results [9].

It may be tempting to assume that with improved pre-operative optimization, patient selection, and critical care, operative mortality has significantly improved with ABF in the new millennium. However, this assumption has been refuted by published reports, and the reasons are multifactorial. First, as Back demonstrated, ABF is now utilized for patients with increasingly complex anatomy, often requiring suprarenal or supraceliac clamping, and visceral revascularization [10]. Second, fewer ABF are being performed, and Dimick’s previously referenced work demonstrated mortality rate of 3.7 % for low-volume hospitals (<25 ABF/year) compared to 2.2 % for high-volume hospitals (>25 ABF/year) [8]. Third, as endovascular therapy further matures, newer vascular surgeons will have had less open training compared to their more senior counterparts, which will further exacerbate challenges with ABF. It is predicted that by 2015, vascular trainees will complete fellowship having performed only 10 open aortic repairs, and by 2020, only 5 [11].

Morbidity from ABF is generally categorized into systemic (e.g. MI, pneumonia, sepsis, stroke) versus local (e.g. hematoma, lymphocutaneous fistula, surgical site infection). A large proportion of systemic complications are pulmonary. A meta-analysis by de Vries reported a systemic morbidity of 12 % and local morbidity of 7 % in ABF results spanning four decades, whereas Chiu reported 16 % and 6 % respectively over a similar timeframe [7, 9] (Table 12.2).

Endovascular therapy for aortoiliac arterial occlusive disease (AIOD) is an appealing alternative to ABF. It can be performed percutaneously or with open femoral arterial exposure, without general anesthesia, and can be combined with adjunctive procedures without taking on significantly more risk.

Although endovascular therapy is often provided to those with prohibitive cardiopulmonary risk for open surgery, mortality is still less than 1 %, based on a weighted average extracted from a recent systematic review of 1711 patients [12]. However, it is important to note that these are high-risk patients undergoing a low-to-medium risk procedure, and mortality in high volume single institution retrospective studies can sometimes be as high as 4 %. Therefore, caution is advised even for endovascular therapy.

In contrast to ABF, morbidity resulting from endovascular treatment of AIOD consists predominantly of local or arterial complications. Hematoma, pseudoaneurysm, retro-peritoneal hemorrhage, arterial dissection, arterial perforation, and distal emboli have been described [13]. Systemic complications are less common, but MI, renal injury, pulmonary edema, stroke, and others, as a whole, occur at a range of about 3–4 % [14]. Combined, the morbidity rate is about 13 % when a weighted average is calculated from Jongkind’s systemic review. A smaller meta-analysis of 323 TASC C/D cases reported a morbidity rate of 15 %, of which three quarters were local complications [14] (Table 12.3).