Outcomes of axillofemoral and aortofemoral bypass for intermittent claudication may be similar

Abstract

Despite almost 40 years of experience with axillofemoral grafts, there remains an absence of clear guidelines for their use, especially in treating intermittent claudication (IC). This motivated Levin et al1Levin S.R. Farber A. King E.G. Beck A.W. Osborne N.H. DeMartino R.R. et al.Outcomes of axillofemoral bypass for intermittent claudication.J Vasc Surg. 2021; 75: 1687-1694Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar to examine the Vascular Quality Initiative (VQI) database to evaluate the appropriateness of axillofemoral bypass for IC. Although apparently their aim was not to compare axillofemoral bypass data with aortofemoral bypass grafts, much of their paper is devoted to such a comparison. On the basis of this evaluation, they first conclude that axillofemoral bypass is associated with significant perioperative morbidity, mortality, and long-term complications, and second, serious consideration should be given before its use for IC. Critical review posits that their second conclusion is correct and admirable, but the first may not be entirely accurate. In assessing an operative technique that involves a bypass graft, all preoperative, intraoperative, and postoperative variables and outcomes need to be considered to determine its efficacy and clinical benefit. Although the VQI is a formidable database, concerning axillofemoral bypass many confounding factors were not recorded. These include the status of the donor subclavian/axillary artery, the use of heparin surfaced grafts, postoperative surveillance protocols, and interventions to maintain patency of the donor artery. Indeed, recent papers2Samson R.H. Showalter D.P. Lepore M.R. Nair D.G. Dorsay D.A. Morales R.E. Improved patency after axillofemoral bypass for aortoiliac occlusive disease.J Vasc Surg. 2018; 68: 1430-1437Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar,3Hardouin S. Cheng T.W. Farber A. Kalish J.A. Jones D.W. Malas M.B. et al.Axillarybifemoral and axillary-unifemoral artery grafts have similar perioperative outcomes and patency.J Vasc Surg. 2020; 71: 862-868Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar have demonstrated excellent patency rates when heparin-bonded axillofemoral polytetrafluoroethylene grafts had been used or with axillary arteries that were proven normal or endovascularly treated to be, or remain, an acceptable donor vessel. Further, it is critical that if axillofemoral grafts are compared with the "gold standard" aortofemoral procedures, variables must be equivalent. In this report, patients undergoing axillofemoral grafts were more often older, female, had noncommercial insurance, ambulated with assistance, had a previous inflow bypass, ipsilateral leg bypass, peripheral endovascular intervention, and major amputation. Further, they were more often hypertensive, more likely to have coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, anemia, and end-stage renal disease (P < .05 for all). Despite these significant risk factors, axillofemoral bypass was accompanied by a shorter length of stay, fewer pulmonary and renal complications, and, assuming these results, possibly lower cost. Further, despite these morbidities, they did not suffer more postoperative medical complications or operative mortality. Extensive comorbidities may also explain the difference in survivors’ amputation rate (5.2% vs 2%) and graft occlusion (7% vs 3.6%). However, the latter difference may also result from failure to use the more current heparin-bonded polytetrafluoroethylene or dual antiplatelet and statin therapy. Further, researchers must be leery of combined end points where one of its constituents significantly outweighs the others. For example, the authors reveal that 1-year ipsilateral reintervention/amputation/death was more likely with axillofemoral grafts, yet it is notable that occlusion/death and amputation/death were similar between cohorts. What then is the takeaway? First, appropriately surgeons who enter data into the VQI are more likely to use axillofemoral bypass grafts for high-risk patients. Second, even aortofemoral bypass grafts have significant morbidity and mortality. Therefore, the authors’ conclusion is correct that serious consideration should be given before axillofemoral bypass for IC. However, this conservative approach applies equally to aortofemoral bypass procedures. 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. Outcomes of axillofemoral bypass for intermittent claudicationJournal of Vascular SurgeryVol. 75Issue 5PreviewAlthough endovascular therapy is often the first-line option for medically refractory intermittent claudication (IC) caused by aortofemoral disease, suprainguinal bypass is often performed. Although this will often be aortofemoral bypass (AoFB), axillofemoral bypass (AxFB) is still sometimes performed despite limited data evaluating its utility in the management of IC. Our goal was to assess the safety and durability of AxFB performed for IC. Full-Text PDF