Operative Complexity and Prior Endovascular Intervention Negatively Impact Morbidity after Aortobifemoral Bypass in the Modern Era.

Abstract

BACKGROUND\nEndovascular therapy is first-line treatment for aortoiliac occlusive disease. This shift has altered case volume, patient selection, and risk profile for aortobifemoral bypass (ABF). Given this, we sought to investigate factors influencing morbidity and mortality after ABF in the endovascular era.\n\n\nMETHODS\nData for patients undergoing primary ABF from 2000 to 2017 were queried. Primary endpoints included major complication (unplanned return to OR, life-or-limb-threatening complications, and 30-day readmission or death) and long-term survival. Logistic regression and cox proportional hazards models determined predictors of primary endpoints. Kaplan-Meier analysis estimated long-term survival.\n\n\nRESULTS\nDuring this 17-years, 256 patients underwent primary ABF. Mean age was 67.9±10.6 years and 51.2% were women. Most had claudication (69.5%); 28.9% had critical ischemia. Sixty-five (25.4%) patients had prior aortoiliac endovascular intervention, 106 (41.4%) required aortic cuff endarterectomy, 111 (43.3%) femoral outflow adjunct, 9 (3.5%) simultaneous lower extremity bypass, and 230 (89.8%) had TASC D lesions. Concomitant renovisceral revascularization was needed in 42 (16.4%) patients. Thirty-day mortality was 2.7%. Major complication occurred in 92 patients (35.9%). Predictors included prior endovascular intervention (OR 2.2, 95% CI: 1.2-4.1; p=0.01), malignancy (OR 2.6, 95%CI: 1.3-5.3; p=0.01), intraoperative complication (OR 3.3, 95%CI: 1.3-9.2; p=0.03), operative blood loss, (OR 1.0 per 100ml, 95%CI: 1.0-1.0; p=0.03), and cuff endarterectomy (OR 1.8, 95%CI: 1.0-3.1; p=0.04). Median follow-up was 5.3 years (interquartile range: 7.2 years). Survival at 1, 3, and 5-years was 94%, 90%, and 82% respectively. Primary patency and freedom from reintervention at 5-years were 76% and 79%, respectively. Predictors of late mortality included malignancy (HR 2.3, 95%CI: 1.3-3.9; p<0.01), COPD (HR 1.8, 95%CI: 1.1-3.1; p=0.02), CHF (HR 2.3, 95%CI: 1.2-4.3; p=0.01), Rutherford s class (HR 1.5, 95%CI: 1.1-2.1; p=0.01), operative blood loss (HR 1.0 per 100ml, 95%CI: 1.0-1.0; p=0.04) and CKD (HR 2.3, 95%CI: 1.2-4.2; p=0.01).\n\n\nCONCLUSION\nAlthough late outcomes after ABF in the contemporary era remain acceptable, major complications are frequent. Operative complexity and prior endovascular revascularization predict complications. Long-term survival is driven by degree of limb-ischemia and comorbidities. These should be considered in selection for ABF, potentially modifying approach to improve outcomes.