Comparison of Open Aortoiliac Disease Reconstructions in the Modern Era
Trung Nguyen1, Dean J Arnaoutakis1, Charles Bailey1, Young Kim2, Rajavi Parikh1, Murray Shames1, Christopher Latz1
1University of South Florida, Tampa, FL;2Duke University Hospital, Durham, NC
Objectives: Management of aortoiliac occlusive disease has changed drastically with the advent of newer and more effective endovascular technologies and techniques. However, open aortoiliac reconstructive techniques still play a large role in the management of complex lesions. The goal of this study is to compare the modern 30-day outcomes of death and wound complication of the three most common forms of open aortoiliac reconstruction [(Aorto-bi-femoral bypass, ABF), Axillo-femoral bypass (AxFB) and femoro-femoral bypass (FFB)], as well as to endovascular therapy (ET) as a comparative arm.
Methods: The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing open or endovascular aortoiliac intervention from 2011-2021. All emergency cases and preoperative septic cases were excluded. Cohorts were divided into ABF, AxFB, FFB and ET. The ET group included only advanced lesions requiring distal aortic angioplasty/stenting, bilateral common iliac artery interventions or concurrent common and external interventions. The primary 30-day outcomes were mortality and wound complication. Wound complication included wound infections and documented dehiscence. Univariate analyses were performed using the Chi-Square test and the Student’s t-test. Multivariable analysis was performed using logistic regression.
Results: From 2011 to 2021, 8,174 patients met study criteria. There were 2,659 (32.5%) patients in the ABF cohort, 1,003 (12.27%) underwent AxFB, 2,367 (29.0%) underwent FFB and 2,145 (26.2%) underwent ET. Mortality rate was 2.6% for ABF, 3.4% for AxBF, 0.8% for FFB and 0.8% for ET (Table 1). After adjustment, mortality AOR compared to ABF was 0.61, 95% CI [0.39-0.96], p=.03 for AxFB, 0.18 95% CI [0.11-0.31], p<.001 for FFB, and 0.20, 95% CI
[0.11-0.35], p<.001 for ET. Mortality compared to AxFB for FFB demonstrated an AOR=0.30 (95% CI: 0.17-0.54), p< 0.001 and ET AOR=0.33 (95% CI: 0.18-0.63), p=0.001. Wound complication AOR compared to ABF was 1.28, 95% CI (0.98-1.67), p=0.07 for AxFB; 1.01, 95% CI (0.81-1.26) for FFB and 0.28, 95% CI (0.21-0.40), p< 0.001 for ET.
Conclusion: AxFB, FFB and ET all have reduced mortality compared to ABF. FFB and ET have decreased mortality compared to AxFB. Wound complication rates were similar for all three open procedures and were significantly higher than the endovascular arm.
Figure 1: Unadjusted mortality rate per aortoiliac procedure.
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