Midterm outcomes of aortobifemoral bypass, axillobifemoral bypass and covered endovascular reconstruction of aortic bifurcation.

Abstract

Objectives: Aortobifemoral bypass (ABFB) is the gold-standard procedure for aortoiliac occlusive disease (AIOD). Axillobifemoral bypass (AxBFB) has been alternatively used for revascularization in patients who are deemed high risk for ABFB. However, in the endovascular era, covered endovascular reconstruction of aortic bifurcation (CEARB) is being used frequently in high- and standard-risk patients with AIOD. We aimed to compare the midterm outcomes of ABFB, AxBFB, and CERAB in the Vascular Quality Initiative (VQI)-Medicare-Linked database.

Methods: All patients with AIOD who underwent aortoiliac reconstruction by ABFB, AxBFB or CERAB during 2013-2019 in VQI-Medicare-Linked database were included. The primary outcome was amputation-free survival (AFS). The secondary outcomes were overall survival (OS), limb salvage (LS), and freedom from reintervention (FFR). Outcomes were assessed at one- and three-years. Kaplan-Meier estimates and Cox regression were used for the analyses.

Results: Three cohorts of patients undergoing ABFB (N=1,906, 60.4%), AxBFB (N=1,077, 34.1%) and CERAB (N=173, 5.5%) were studied. The patients in AxBFB and CERAB cohorts were older than the ABFB cohort and were more likely to have comorbidities compared to their ABFB counterparts. Three-year AFS was 79.4%, 54.6%, 71.1% in ABFB, AxBFB and CERAB cohorts, respectively (P<.001). After adjusting for potential confounders, AxBFB was associated with higher hazards of major amputation/death compared to ABFB at three-year (adjusted Hazard Ratio[aHR]=1.89, 95% Confidence Interval [CI], 1.61-2.23; P<.001) but CERAB was not (aHR=1.27, 95% CI, 0.84-1.91; P=0.251). AxBFB was also associated with higher hazards of major amputation compared to ABFB at three-year (aHR=1.74, 95% CI, 1.05-2.90; P=0.032) but CERAB was not (aHR=2.14, 95% CI, 0.73-6.31; P=0.166). On the other hand, CERAB was associated with increased hazards of three-year reintervention (aHR=1.75, 95% CI, 1.16-2.64; P=0.007) compared to ABFB. CERAB was also associated with lower hazards of major amputation/death at one-year compared to AxBFB (aHR=0.62, 95% CI, 0.38-0.99; P=0.048) but not at three-year.

Conclusions: We found that CERAB is comparable to ABFB in terms of OS, LS and AFS, albeit with substantial increase in reintervention rate at three years. AxBFB had worse OS, LS and AFS compared to ABFB. CERAB was associated with higher AFS compared to AxBFB at one-year. This national contemporary study supports the use of CERAB as a safe and durable alternative to ABFB and AxBFB. However, further prospective studies are necessary to confirm our findings.