A contemporary comparison of aortofemoral bypass and aortoiliac stenting in the treatment of aortoiliac occlusive disease.
BACKGROUND
Although aortofemoral bypass (AFB) has historically been the treatment of choice for aortoiliac occlusive disease (AIOD), rates of AFB have declined, while utilization of aortoiliac angioplasty and stenting (AS) has increased dramatically. The objective of the current study was to determine the effect of these trends on treatment outcomes in a contemporary single-institution experience with AIOD.


METHODS
Between 1997 and 2007, 118 AFB and 174 AS procedures were performed in 161 men (55.1%) and 131 women at a single university teaching hospital. Patient outcomes were retrospectively reviewed and analyses were performed using chi-squared/Fisher's exact test and ANOVA. Ankle-brachial index (ABI) interactions between procedure type and Trans-Atlantic Inter-Society Consensus (TASC) category were calculated using a General Linear Model. A reduced Cox model was used to determine the impact of patency, presenting symptoms, duplex surveillance, and procedure type on amputations and revisions. Kaplan-Meier estimates for survival, freedom from amputation, and freedom from revision were used to evaluate long-term outcomes.


RESULTS
There was no difference between AFB and AS groups with respect to 30-day mortality (0.8% and 1.1%, p=0.64), myocardial infarction (1.7% and 1.1%, p=0.53), cerebrovascular accident (0.0% and 1.1%, p=0.35), or renal failure requiring hemodialysis (3.4% and 1.2%, p=0.19). AFB was associated with increased surgical complication rates including the need for emergency surgery (6.8% and 1.7%, p=0.029), infection/sepsis (16.1% and 2.3%, p<0.001), transfusion (16.1% and 5.7%, p=0.004), and lymph leak (8.5% and 0.6%, p=0.001). The difference between preprocedural and postprocedural ABI was greater for AFB than AS (R, 0.39 and 0.18, p<0.001; L, 0.41 and 0.15, p<0.001). This difference was maintained when patients were stratified by TASC category.


CONCLUSIONS
There were no differences between the AFB and AS groups with respect to long-term rates of mortality, amputation, or revision procedures. AFB continues to be performed safely, despite the case numbers in this series correlating with a lower-volume hospital. Morbidities associated with major open surgery in this series were counterbalanced by greater improvements in ABI. Patients and practitioners should continue to entertain both procedure types as viable alternatives for the treatment of AIOD.
Burke
Christopher R
CR
Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
Henke
Peter K
PK
Hernandez
Roland
R
Rectenwald
John E
JE
Krishnamurthy
Venkat
V
Englesbe
Michael J
MJ
Kubus
James J
JJ
Escobar
Guillermo A
GA
Upchurch
Gilbert R
GR
Eliason
Jonathan L
JL
D000671:Amputation, Surgical; D000714:Anastomosis, Surgical; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D000842:Ankle / Q000098:blood supply; D001018:Aortic Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D001027:Aortography; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D001794:Blood Pressure; D001916:Brachial Artery / Q000503:physiopathology; D016009:Chi-Square Distribution; D003251:Constriction, Pathologic; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality