A personal experience with direct reconstruction and extra-anatomic bypass for aortoiliofemoral occlusive disease

• Published in: Journal of vascular surgery 2007-03, Vol.45 (3), p.527-535.e3
• Main Authors: Hertzer, Norman R., MD, Bena, James F., MS, Karafa, Mathew T., PhD
• Format: Article
• Language: English
• Subjects: Age Distribution; Age Factors; Aged; Aortic Diseases - mortality; Aortic Diseases - physiopathology; Aortic Diseases - surgery; Arterial Occlusive Diseases - mortality; Arterial Occlusive Diseases - physiopathology; Arterial Occlusive Diseases - surgery; Female; Femoral Artery - physiopathology; Femoral Artery - surgery; Follow-Up Studies; Humans; Kaplan-Meier Estimate; Logistic Models; Male; Middle Aged; Ohio - epidemiology; Patient Selection; Proportional Hazards Models; Registries - statistics & numerical data; Risk Factors; Sex Distribution; Sex Factors; Surgery; Time Factors; Treatment Outcome; Vascular Patency; Vascular Surgical Procedures - adverse effects; Vascular Surgical Procedures - statistics & numerical data
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2006.09.065

Objective This study was conducted to investigate factors influencing the outcome of all open operations for aortoiliofemoral (AIF) revascularization performed by a single surgeon at a tertiary referral center. Methods The series included 355 direct reconstructions and 181 extra-anatomic bypass (EAB) grafts in 339 men (63%) and 197 women, with median ages of 61 and 62 years, respectively. These procedures were done for claudication alone in 267 patients (50%), for advanced ischemia in 258 (48%), and to facilitate other interventions in 11 (2.0%). Simultaneous infrainguinal bypass was necessary in 36 patients (6.7%). Survival and patency analyses were performed using logistic regression, Kaplan-Meier estimations, and proportional hazards models. Results Patients receiving EAB were older ( P < .001) and were more likely to have advanced preoperative limb ischemia ( P < .001), superficial femoral artery occlusions ( P < .001), a history of previous lower extremity inflow operations ( P < .001), elevated serum creatinine ( P = .017), and clinically severe chronic obstructive pulmonary disease ( P = .016). On multivariable analysis, EAB resulted in a higher incidence of postoperative death (8.8% vs 2.3%, P = .005) or graft thrombosis (8.8% vs 2.8%, P = .006) than direct reconstruction. Women were more likely to sustain graft thrombosis ( P = .006) or require major amputation ( P = .050), or both, during the early postoperative period. Overall late survival rates were 87% ± 3% at 1 year, 64% ± 5% at 5 years, 39% ± 5% at 10 years, and 20% ± 4% at 15 years. Late survival rates were significantly lower ( P = .026) after EAB and also were unfavorably associated with advanced preoperative ischemia ( P = .046) as well as with several medical comorbidities ( P < .001). Primary limb-based patency rates were 95% ± 2% at 1 year, 85% ± 3% at 5 years, 77% ± 5% at 10 years, and 69% ± 7% at 15 years. Late occlusions occurred more frequently in patients who had undergone previous inflow procedures ( P = .028) and were especially common after EAB ( P < .001). Patients >65 years had higher early and late mortality rates than younger patients ( P < .001), but younger patients had lower long-term patency rates ( P < .001). Conclusions The worse operative mortality and late survival rates for EAB in this series largely were preordained by the frequent selection of EAB for patients who represented poor medical risks for direct AIF reconstruction. However, the durability of aortofemo