Superficial Femoral Artery Occlusion Reduces Aortofemoral Bypass Graft Patency

Abstract

The effect of superficial femoral artery (SFA) occlusion on long-term patency of aortofemoral bypasses (AFBs) for aortoiliac occlusive disease (AIOD) was examined. The AIOD database was reviewed to identify risk factors for AFB failure. The status of the SFA at AFB procedure was categorised as patent; diseased treated (DT), if the SFA occlusion was intervened on concomitant to AFB; or diseased untreated (DU), if the SFA was occluded but not revascularised. Censoring hierarchies for primary patency and patent graft survival time were constructed. Data were analysed by contingency table, Kaplan-Meier, and Cox regression analysis. Between 2004 and 2015, 122 AFB (9 unifemoral, 113 bifemoral) for AIOD were performed. Seventy-five (61%) were female and the mean age was 60±10 years. At the time of AFB, 50 (41%) had occluded SFAs (DT/DU). Of these, 15 had concomitant SFA revascularisation (i.e., DT) at the time of AFB. Patients with occluded SFAs had greater history of prior aortoiliac/infrainguinal procedures (aortoiliac 54% vs. 22%, infrainguinal 58% vs. 25%, both p<0.001), Trans-Atlantic Inter-Society Consensus II classification of femoropopliteal type D lesions (78 vs. 10%, p<0.001), Rutherford 4-6 categories (80% vs. 57%, p=0.011), and longer hospital stay (median 11 vs. 7 days, p<0.004). SFA status did not affect 30 day mortality (overall 9%); however, sub-analysis showed DT had significantly higher mortality than DU (p<0.03). Over a median follow up of 7.7 (IQR 4.3-11.4) years, primary patency at one and five years was 98.3% and 91.2% in patients with patent SFAs, 87.9% and 82.7% in DU, and 72.7% and 43.6% in DT (p<0.001), respectively. On multivariable analysis, low baseline glomerular filtration rate (HR 1.01, p=0.022), DT (HR 3.7, p=0.020), Rutherford 4-6 (HR 9.1, p=0.048), and occluded SFA (HR 3.9, p=0.009) adversely affected primary patency of AFBs. Long-term mortality was not different between the SFA status groups (p=0.279). Baseline SFA occlusion predicted a fourfold increased hazard of primary AFB failure. Concomitant SFA revascularisation did not improve AFB durability and was associated with increased in hospital mortality.