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Aortobifemoral bypass vs covered endovascular reconstruction of aortic bifurcation
Dana B Semaan1, Salim G Habib1, Othman M Abdul-Malak2
1Department of Surgery, Allegheny Health Network, Pittsburgh, PA.
Insights
Covered endovascular reconstruction of aortic bifurcation (CERAB) offers lower perioperative morbidity than aortobifemoral bypass (ABF) for AIOD patients. However, CERAB shows higher rates of major adverse limb events and reinterventions, necessitating further long-term outcome studies.
Area of Science:
- Vascular Surgery
- Endovascular Interventions
- Aortoiliac Disease Management
Background:
- Covered endovascular reconstruction of aortic bifurcation (CERAB) is a growing first-line treatment for aortoiliac occlusive disease (AIOD).
- Comparison with the established aortobifemoral bypass (ABF) is crucial for understanding CERAB's efficacy and safety.
Purpose of the Study:
- To compare the 1-year outcomes of CERAB versus ABF in patients with AIOD.
- To evaluate primary patency, major adverse limb events (MALEs), survival rates, and reintervention rates.
Main Methods:
- Analysis of the Vascular Quality Initiative database (2009-2021) for ABF and CERAB procedures.
- Propensity score matching (5-to-1 nearest-neighbor) to balance patient demographics and comorbidities.
- Primary outcomes included 1-year estimates of primary patency, MALEs, MALE-free survival, reintervention-free survival, and amputation-free survival.
Main Results:
- CERAB patients were older and had more comorbidities (diabetes, ESRD) than ABF patients.
- Matched analysis showed ABF had better MALE-free survival (93.2% vs. 83.2%) and lower MALE rates (5.2% vs. 14.1%).
- Primary patency and amputation-free survival were comparable; CERAB had significantly lower reintervention-free survival (62.5% vs. 92.9%) but shorter hospital stays and fewer pulmonary, renal, and cardiac complications.
Conclusions:
- CERAB demonstrates lower perioperative morbidity and comparable 1-year primary patency to ABF.
- CERAB is associated with increased major adverse limb events and reinterventions compared to ABF.
- Further long-term studies are needed to define CERAB's role in AIOD treatment versus the durability of ABF.
Background:
Covered endovascular reconstruction of aortic bifurcation (CERAB) is increasingly used as a first line-treatment in patients with aortoiliac occlusive disease (AIOD). We sought to compare the outcomes of patients who underwent CERAB compared with the gold standard of aortobifemoral bypass (ABF).
Methods:
The Vascular Quality Initiative was queried for patients who underwent ABF or CERAB from 2009 to 2021. Propensity scores were generated using demographics, comorbidities, Rutherford class, and urgency. The two groups were matched using 5-to-1 nearest-neighbor match. Our primary outcomes were 1-year estimates of primary patency, major adverse limb events (MALEs), MALE-free survival, reintervention-free survival, and amputation-free survival. Standard statistical methods were used.
Results:
A total of 3944 ABF and 281 CERAB cases were identified. Of all patients with AIOD, the proportion of CERAB increased from 0% to 17.9% between 2009 and 2021. Compared with ABF, patients who underwent CERAB were more likely to be older (64.7 vs 60.2; P < .001) and more often had diabetes (40.9% vs 24.1%; P < .001) and end-stage renal disease (1.1% vs 0.3%; P = .03). In the matched analysis (229 CERAB vs 929 ABF), ABF patients had improved MALE-free survival (93.2% [±0.9%] vs 83.2% [±3%]; P < .001) and lower rates of MALE (5.2% [±0.9%] vs 14.1% [±3%]; P < .001), with comparable primary patency rates (98.3% [±0.3%] vs 96.6% [±1%]; P = .6) and amputation-free survival (99.3% [±0.3%] vs 99.4% [±0.6%]; P = .9). Patients in the CERAB group had significantly lower reintervention-free survival (62.5% [±6%] vs 92.9% [±0.9%]; P < .001). Matched analysis also revealed shorter length of stay (1 vs 7 days; P < .001), as well as lower pulmonary (1.2% vs 6.6%; P = .01), renal (1.8% vs 10%; P < .001), and cardiac (1.8% vs 12.8%; P < .001) complications among CERAB patients.
Conclusions:
CERAB had lower perioperative morbidity compared with ABF with a similar primary patency 1-year estimates. However, patients who underwent CERAB experienced more major adverse limb events and reinterventions. Although CERAB is an effective treatment for patients with AIOD, further studies are needed to determine the long-term outcomes of CERAB compared with the established durability of ABF and further define the role of CEARB in the treatment of AIOD.
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