Aortobifemoral bypass remains more durable long-term compared to endovascular intervention for aortoiliac occlusive
Elonay Yehualashet1, Lindsey Olivere1, Xinyan Zheng2
1Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA.
Insights
Aortoiliac occlusive disease (AIOD) treatment comparison shows aortobifemoral bypass (ABF) offers better long-term limb salvage than peripheral endovascular intervention (PVI). ABF improved outcomes for critical limb ischemia, while PVI led to more reinterventions for claudication.
Area of Science:
- Vascular Surgery
- Endovascular Interventions
- Comparative Effectiveness Research
Background:
- Peripheral endovascular intervention (PVI) is a first-line treatment for aortoiliac occlusive disease (AIOD).
- Long-term data comparing PVI to aortobifemoral bypass (ABF) is limited.
- Existing studies often come from single institutions.
Purpose of the Study:
- To compare the long-term efficacy and durability of PVI versus ABF for de novo AIOD.
- To evaluate outcomes including major adverse limb event-free survival (MALE-FS), amputation-free survival (AFS), reintervention-free survival (RFS), and overall survival.
- To analyze outcomes based on patient presentation (chronic limb threatening ischemia vs. claudication).
Main Methods:
- Utilized Vascular Quality Initiative (VQI) data linked with Medicare claims (2010-2019).
- Included 4,282 de novo AIOD interventions (ABF or suprainguinal PVI), excluding emergent cases.
- Employed Kaplan-Meier analysis and Cox regression for comparative outcome assessment, including subgroup analyses.
Main Results:
- Five-year MALE-FS was significantly lower for PVI (38.2%) compared to ABF (58.7%).
- ABF demonstrated superior 5-year AFS (70.5% vs. 60.1%) and RFS (59.0% vs. 38.4%).
- ABF was associated with reduced risk of major amputation or death in chronic limb threatening ischemia (CLTI) patients, while PVI showed higher reintervention rates for claudication.
Conclusions:
- Suprainguinal PVI durability may not match long-term expectations for AIOD treatment.
- Aortobifemoral bypass (ABF) may provide superior limb preservation for CLTI patients.
- Patients with claudication may benefit from ABF due to potentially lower reintervention rates compared to PVI.
Background:
Peripheral endovascular intervention (PVI) has become a first-line treatment for aortoiliac occlusive disease. Although short- and mid-term data for PVI is strong, long-term comparative efficacy and durability of these interventions compared with aortobifemoral bypass (ABF) have not been well studied beyond single-institutional experiences.
Methods:
Vascular Quality Initiative datasets were queried for de novo aortoiliac interventions (ABF or suprainguinal PVI) and linked to Medicare claims (2010-2019) (Vascular Quality Initiative and Vascular Implant Surveillance and Interventional Outcomes Network). Emergent cases were excluded. Primary outcome was 5-year estimates of major adverse limb event-free survival (MALE-FS; freedom major amputation, reintervention or death). Secondary outcomes were 5-year estimates of major amputation-free survival (AFS; freedom from major amputation or death), reintervention-free survival (freedom from reintervention or death), and survival. Kaplan-Meier analysis compared outcomes between ABF vs PVI. Adjusted analysis was performed using Cox regression. Subgroup analysis compared patients presenting with chronic limb-threatening ischemia (CLTI) vs claudication.
Results:
We identified 4282 cases, including 931 ABF (21.7%) and 3351 PVI (78.2%; 8.8% with concurrent femoral endarterectomy). Overall, there was increased PVI utilization (2010-2014: 32.2%; 2015-2019: 67.8%; P = .011). Patients undergoing PVI were more likely to be older, live in urban areas, have higher rates of comorbidities, and present with claudication (68.1% vs 58.3%; P < .001). Five-year MALE-FS was 58.7% in the ABF group and 38.2% in the PVI (P < .001). The difference in rates of MALE and death favoring ABF persisted in adjusted analysis [adjusted hazard ratio (aHR), 0.544; 95% confidence interval (CI), 0.474-0.626; P < .001]. This remained true for patients treated for both claudication (aHR, 0.562; 95% CI, 0.466-0.679; P < .001) and CLTI (aHR, 0.532; 95% CI, 0.434-0.652; P < .001). Five-year AFS was 70.5% among patients undergoing ABF and 60.1% among patients with PVI (P < .001), whereas reintervention-free survival was 59.0% and 38.4%, respectively (P < .001). Survival was also greater with ABF among patients presenting with CLTI (66.4% vs 44.6%; P < .001). On subgroup analysis, ABF was independently associated with reduced risk of major amputation or death only among patients with CLTI (aHR, 0.681; 95% CI, 0.533-0.870; P = .002). There was no difference in AFS between ABF and PVI in patients with claudication, suggesting the reduced MALE-FS in patients undergoing PVI for claudication is driven by higher reintervention rates.
Conclusions:
Despite a continued temporal shift toward an endovascular-first approach for aortoiliac occlusive disease, durability of suprainguinal PVI may not persist long-term. In medically appropriate patients, ABF may offer patients with CLTI improved limb preservation, whereas patients with claudication may experience reduced rates of reintervention.
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