National Comparison of Hybrid and Open Repair for Aortoiliac-Femoral Occlusive Disease

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The purpose of this study was to analyze the outcomes of revascularization for aortoiliac-femoral occlusive disease by comparing hybrid repair (endovascular repair and open common femoral endarterectomy [ER-CFE]) with open aortoiliac reconstruction and CFE (OR-CFE). Using the national Society for Vascular Surgery Vascular Quality Initiative database from 2006 to 2015, we identified all patients receiving open or endovascular revascularization of the aortoiliac system and who additionally underwent CFE. Patients with concomitant infrainguinal procedures were excluded. Main outcome variables were 30-day mortality, length of stay, 1-year mortality and patency, ankle-brachial index (ABI), secondary interventions, major amputations, and ambulatory status. The cohort comprised 2524 patients receiving ER-CFE and 1324 patients receiving OR-CFE. Patients with ER-CFE were older (68 ± 0.2 vs 63 ± 0.3 years; P < .01) and were more likely to have diabetes (36% vs 29%; P < .001) and heart failure (14% vs 9%; P < .01). Those receiving OR-CFE were more likely to have received a previous inflow procedure (25% vs 20%; P < .001). A greater number of arterial segments were treated for patients undergoing OR-CFE (5.2 ± 1.6 vs 2.9 ± 1.0; P < .01). ER-CFE was associated with lower 30-day mortality (2.3 % vs 3.9%; P = .004) and shorter length of stay (median, 3 vs 7 days; P < .01). Follow-up was available for 44.1% of the cohort (44.3% OR-CFE vs 44.0% ER-CFE; P = NS). Those receiving ER-CFE had higher 1-year mortality (10.6% vs 6.2%; P < .01), fewer reinterventions (7.2% vs 10.3%; P = .03), and equivalent major amputation rate (3.3%). Patients with OR-CFE had greater improvement in ABI (0.40 ± 0.4 vs 0.26 ± 0.4; P < .001) and were more likely to achieve improved ambulatory status (82.0% vs 67.6%; P < .01). For patients with aortoiliac-femoral occlusive disease, endovascular repair with concomitant CFE appeared to have improved short-term outcomes and equivalent freedom from major amputation compared with open surgical repair with CFE. Conversely, open repair with CFE was associated with better long-term improvement in ABI and ambulatory status. Open repair should therefore be considered for patients with aortoiliac-femoral occlusive disease and reasonable surgical risk.