Invited commentary

Abstract

Sharma and colleagues from the Brigham have shown that aortobilateral femoral bypass remains an important reconstruction in select patients with advanced aortoiliofemoral artery disease, despite the preferential use of endovascular therapy in these patients. Several important findings are evident from this analysis, some of which corroborate prior publications on this topic, and others that are new. First, experienced aortic surgeons can perform the operation with low mortality, less than 1% in the historic and contemporary cohorts. The mortality rate in this series is less than one-half that reported in broader practice assessments, such as the National Surgical Quality Improvement Program. Second, patency was lower in the contemporary cohort, driven by more extensive atherosclerotic disease, particularly in young patients; differences in prior aortic surgery; and a greater number of patients having aortobilateral femoral bypass for chronic limb ischemia. There is no doubt that common and deep femoral endarterectomy as an adjunct to aortobilateral femoral bypass is necessary more now than what it was two decades ago. The deep femoral artery remains the most important outflow vessel associated with long-term durability in most series. Although not mentioned by the authors, I wonder if patients whose distal anastomoses were to the superficial femoral artery had lower patency. Third, durability and limb salvage rates with this operation remain excellent. Moreover, the 10-year survival was better in the contemporary cohort, even though peripheral atherosclerotic disease burden was high. This difference likely is due to less coronary artery disease and significantly greater number of patients on statin, beta-blocker, and antiplatelet agents, as the authors note. Clearly, aggressive risk factor modification is beneficial. The study lacks in some detail, such as a comparison with matched patients treated by endovascular techniques, the extent of iliac (most had TransAtlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease class C and D disease) and infrainguinal disease, which impacts patency, surgeon choice for treatment, and specific technical details. Interestingly, more than one-half of the patients in the contemporary group had end-to-side aortic anastomoses for reasons that are unclear. Our preference has been for end-to-end aortic anastomoses except the rare circumstances in which there is a large inferior mesenteric artery, multiple renal arteries, or external iliac artery occlusions in which pelvic blood flow needs to be maintained. Configuration and length of the body of a graft sewn end-to-side is important to avoid buckling and kinking of the graft limbs, which impacts patency. No mention is made about aortoiliac occlusion versus diffuse disease, either of which may affect operative approach and choice of clamp position. Nonetheless, the clinical outcomes in this study are exemplary. The Brigham group rightly raises questions as to whether such results can be broadly applied to practices at large, and if there will be experienced open aortic surgeons to perform such operations in the future. There is no doubt that aortofemoral reconstruction is still necessary. The authors stress the importance of maintaining open aortic surgical skills, a challenge today in many training programs. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Thirty-year trends in aortofemoral bypass for aortoiliac occlusive diseaseJournal of Vascular SurgeryVol. 68Issue 6PreviewEndovascular intervention has supplanted open bypass as the most frequently used approach in patients with aortoiliac segment atherosclerosis. We sought to determine whether this trend together with changing demographic and clinical characteristics of patients undergoing aortobifemoral bypass (ABFB) for aortoiliac occlusive disease (AOD) have an association with postoperative outcomes. Full-Text PDF Open Archive