In-Hospital Outcomes of Aortoiliac Versus Aortofemoral Bypass in Aortoiliac Occlusive Disease in Vascular Quality Initiative

Abstract

This study evaluated the in-hospital outcomes of patients undergoing aortoiliac bypass vs aortofemoral bypass for the treatment of aortoiliac occlusive disease using data obtained from the Vascular Quality Initiative. Surgeries listed in the Vascular Quality Initiative that occurred during the period from January 2009 to June 2021 were queried. The primary outcome was surgical site infection (SSI). The secondary outcomes included in-hospital mortality, postoperative myocardial infarction, postoperative congestive heart failure, return to the operating room, and postoperative major amputation. Logistic regression modeling was used to adjust for potential confounders. A total of 7006 aortofemoral bypasses (90.0%) and 781 aortoiliac bypasses (10.0%) were analyzed. Most of the surgeries were performed bilaterally (aortofemoral, 95.6%; aortoiliac, 92.3%). The patients in the aortofemoral group were older (age, 60.4 ± 8.7 years vs 58.0 ± 9.6 years; P < .001) and more likely to be male (60.1% vs 36.6%; P < .001) and non-White (13.7% vs 10.9%; P = .030) compared with the aortoiliac group. The patients in the aortofemoral group also had significantly greater rates of hypertension (80.5% vs 72.7%; P < .001), coronary artery disease (22.9% vs 19.3; P = .022), and prior cardiovascular interventions, including coronary artery bypass graft/percutaneous coronary intervention (22.2% vs 17.7%; P = .003), carotid endarterectomy/carotid artery stenting (7.9% vs 5.8%; P < .001), and peripheral vascular intervention (6.5% vs 3.1%; P < .001). Patients undergoing aortofemoral interventions had significantly greater rates of both previous lower extremity intervention (12.8% vs 8.6%; P = .001) and concomitant lower extremity intervention (6.4% vs 2.8%; P < .001; Table I). Aortofemoral procedures were significantly associated with higher rates of SSIs (adjusted odds ratio, 2.4; 95% confidence interval, 1.3-4.4; P = .006) and postoperative congestive heart failure (adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.5; P = .029) compared with aortoiliac procedures. Although aortofemoral procedures were associated with greater rates of myocardial infarction compared with aortoiliac procedures (3.3% vs 1.9%; P = .040), this association did not remain significant on multivariate analysis. In-hospital death, a return to the operating room, and postoperative major amputation did not significantly differ between the two surgical techniques (Table II). Patients undergoing aortoiliac bypass had significantly lower rates of SSIs compared with those undergoing aortofemoral bypass. This likely resulted from the avoidance of groin incisions, which is known to be associated with a significantly greater risk of infections in vascular procedures. If anatomically feasible, the aortoiliac configuration in aortic reconstructions should be preferred to reduce the risk of SSI.Table IBaseline and clinical characteristics stratified by distal bypass targetCharacteristicAortofemoral (n = 7006; 90.0%)Aortoiliac (n = 781; 10.0%)P valueAge, years60.4 ± 8.758.0 ± 9.6<.001Male sex4210 (60.1)286 (36.6)<.001Non-White958 (13.7)85 (10.9).030Ethnicity (Hispanic or Latino)159 (2.3)16 (2.1).694Obesity1465 (20.9)230 (29.5)<.001Insurance.053 Medicare2124 (34.0)218 (30.3) Medicaid884 (14.2)94 (13.1) Other3241 (51.9)407 (56.6)Smoking<.001 Never132 (1.9)35 (4.5) Prior2282 (32.6)268 (34.3) Current4585 (65.5)478 (61.2)HTN5629 (80.5)563 (72.7)<.001DM1766 (25.2)208 (26.6).395CAD1605 (22.9)151 (19.3).022Prior CABG/PCI1557 (22.2)138 (17.7).003CHF508 (7.3)37 (4.7).009COPD2336 (33.4)241 (30.9).155Dialysis32 (0.5)5 (0.6).481CKD1048 (15.1)122 (15.8).606Nonambulatory149 (2.1)14 (1.8).533ASA class.172 114 (0.2)1 (0.1) 2260 (3.7)43 (5.5) 35189 (74.2)572 (73.3) 41528 (21.9)164 (21.0) 51 (0.0)0 (0.0)Prior peripheral intervention461 (6.5)24 (3.1)<.001Prior CEA/CAS554 (7.9)45 (5.8)<.001Prior aneurysm repair73 (1.0)22 (2.8)<.001Prior major amputation101 (1.4)11 (1.4).945Aspirin5140 (73.5)551 (70.6).093P2Y12 inhibitor1291 (18.5)125 (16.0).093Statin5262 (75.2)560 (71.7).033Beta-blocker3202 (45.8)339 (43.5).222RAAS inhibitor2906 (46.3)302 (42.0).029Anticoagulant542 (8.6)63 (8.8).908Urgent787 (11.2)94 (12.0).505Anesthesia (general)6889 (98.4)768 (98.3).962Right side indication.001 Asymptomatic/claudication4301 (61.6)506 (64.8) CLTI2258 (32.3)213 (27.3) Acute ischemia310 (4.4)53 (6.8) Not treated117 (1.7)9 (1.2)Left side indication<.001 Asymptomatic/claudication4292 (61.4)538 (69.1) CLTI2315 (33.1)175 (22.5) Acute ischemia285 (4.1)53 (6.8) Not treated94 (1.4)13 (1.7)Previous inflow intervention1747 (25.0)175 (22.5).120Previous LE intervention894 (12.8)67 (8.6).001Concomitant LE intervention445 (6.4)22 (2.8)<.001Bilateral surgery6697 (95.6)721 (92.3)<.001ASA, American Society of Anesthesiology; CABG, coronary artery bypass graft; CAD, coronary artery disease; CAS, coronary artery stenting; CEA, carotid endarterectomy; CHF, congestive heart failure; CKD, chronic kidney disease; CLTI, critical limb threatening ischemia; COPD, chronic pulmonary obstructive disease; DM, diabetes mellitus; HTN, hypertension; LE, lower extremity; PCI, percutaneous coronary intervention; RAAS, renin-angiotensin-aldosterone system.Data presented as mean ± standard deviation or number (%). Open table in a new tab Table IIPostoperative outcomes of aortofemoral vs aortoiliac bypass for aortoiliac occlusive diseaseOutcomeUnadjusted, No. (%)AdjustedaAortofemoral (n = 7006; 90.0%)Aortoiliac (n = 781; 10.0%)P valueaOR (95% CI)P valueSurgical site infection271 (3.9)12 (1.5).0012.4 (1.3-4.4).006In-hospital death167 (2.4)14 (1.8).2971.1 (0.6-2.1).763Postoperative MI229 (3.3)15 (1.9).0401.4 (0.8-2.3).193Postoperative CHF216 (3.1)10 (1.3).0042.2 (1.1-4.5).029Return to operating room694 (9.9)65 (8.3).1561.1 (0.8-1.5).559Postoperative major amputation68 (1.0)9 (1.2).6280.5 (0.3-1.1).087aOR, adjusted odds ratio; CHF, congestive heart failure, CI, confidence interval; MI, myocardial infarction.aReference: aortofemoral. Open table in a new tab