Temporal Trends in Open Revascularization for Aortoiliac Occlusive Disease

Aortobifemoral bypass grafting (AOFBG) and axillobifemoral bypass grafting (AXFBG) are two options for open reconstruction of severe aortoiliac occlusive disease (AIOD). Historically, AOFBG has been considered the gold standard operation for such patients. However, individuals with multiple prior abdominal operations and those deemed too high risk for an open abdominal operation may be better suited for an extra-anatomic bypass. With the advancement of endovascular interventions, these surgical procedures are increasingly being replaced with aortoiliac stenting as the first line of treatment. Now, AOFBG and AXFBG are generally reserved as second-line options, following failure of an endovascular intervention. Understanding characteristics of those who ultimately undergo AOFBG versus AXFBG can provide insights into changing clinical practice patterns and changing operative experience for vascular trainees.

We conducted a retrospective analysis using the National Surgical Quality Improvement Program data from 2016 to 2022 to evaluate trends in AOFBG and AXFBG procedures in patients with peripheral artery disease. We used descriptive statistics to examine patient demographics and comorbidities as well as frequency of AOFBG versus AXFBG to assess changes in the utilization of these procedures over time. Logistic regression models were used to evaluate factors associated with undergoing AOFBG versus AXFBG.

From 2016 to 2022, the annual volume of AOFBG procedures declined sharply, while AXFBGvolume decreased more modestly. Patients undergoing AXFBG were significantly older than those undergoing AOFBG (68.3 vs. 61.5 years), and the proportion of male patients was higher in the AOFBG group (60.4% vs. 54.2%). Racial distribution differed significantly, with a higher proportion of White patients in the AOFBG group (69.7% vs. 65%). In addition to demographics, the AOFBG versus AXFBG groups differed significantly in baseline comorbidities, where current smoking, hypertension, cancer, dialysis dependence, chronic obstructive pulmonary disease, and CHF were all associated with increased utilization of AXFBG as compared to AOFBG.

Among surgical revascularization procedures performed for AIOD, AOFBG demonstrates a greater decrease as compared to AXFBG. However, the differences in baseline characteristics for individuals undergoing AOFBG versus AXFBG still seem to reflect previous practice patterns such that older, sicker patients are more likely to undergo AXFBG. The relatively greater decline in AOFBG may result from the reduction in exposure to open aortic work among vascular surgery trainees and increase in endovascular approach.