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Home > Vascular Annual Meeting > pvss17_dosluoglu_extraanatomic

PVSS17. Extraanatomic Bypass vs. Endovascular Therapy in High Risk Patients with Aorto-Iliac Occlusions

Hasan H. Dosluoglu, Gregory S. Cherr, Purandath Lall, Linda M. Harris, Maciej L. Dryjski.
VA Western NY Healthcare System, SUNY at Buffalo, Buffalo, N.Y.  

OBJECTIVES: The purpose of this study was to compare the outcomes of endovascular revascularization (EVR) to extraanatomic bypass (EAB) for high risk patients with aortoiliac (AI) occlusions.

METHODS: Between 06/2001-05/2007, 77 patients with AI occlusions who were deemed high risk for direct aortoiliac reconstructions underwent either EAB (n=34), or EVR (n=43, 29 percutaneous (PERC), 14 complex hybrid procedures (cHYBRID)) for claudication (35%), rest pain (38)%, and tissue loss (27%). Patient morbidities, patency and survival (Kaplan-Meier) were compared using SPSS.

RESULTS: Mean age and comorbidities were similar between EVR and EAB groups [Table 1]. In EVR group, 7% had TASC (II) B, 23% had C, and 70% had D iliac lesions. Femoral endarterectomy was performed in 29% of EAB, and 93% of cHYBRID groups (p<0.001). Simultaneous infrainguinal bypass was performed in 6% and 21% of EAB and cHYBRID groups. Covered stents were used in 5 patients in cHYBRID, and nitinol bare stents were used in all others. Runoff included both SFA and DFA in 70% of EVR, and 41% of EAB group (p=0.02). ABI increased significantly in all groups, but was significantly higher following EVR than EAB. There was no postoperative mortality, one MI in cHYBRID group (7%), one embolization in PERC group (3%), one hemorrhage in EAB group (3%). Groin wound complications occurred in 8 patients in EAB (24%), and 2 in cHYBRID group (7%), and none in PERC group (p=0.011, PERC vs. others). LOS was significantly less for PERC (1.8±2.2 days) than both EAB (7.2±6.0 days) and cHYBRID (8.1±6.0) groups. Mean follow-up was 32±19 months. Primary, assisted primary, secondary patency, limb salvage and survival were similar between EVR and EAB groups (Table 2). PERC group had better PP (24 month 92±6% vs. 76±7, p=0.089) and APP (96±4% vs. 81±6%, p=0.073) than EAB/cHYBRID groups [Figure 1]. Percutaneous treatment (p=0.089), claudication (p=0.018), and lack of hypertension (p=0.024) were associated with better PP.

CONCLUSIONS: High risk patients with AI occlusions can be treated safely with EAB or EVR with or without concomitant open procedures with similar results. The percutaneously treated patients have shorter LOS, and significantly less morbidity, likely due to less groin complications. Additional interventions at the femoral level is frequently necessary in open and hybrid groups, and the better PP and APP in patients who could be percutaneously treated may simply be a reflection of less overall atherosclerotic disease load.