Abstract
OBJECTIVE: In patients with chronic limb-threatening ischemia (CLTI), extra-anatomical bypasses are viable options to establish inflow when aortic cross-clamping necessary for anatomical reconstruction cannot be tolerated or in those with a hostile abdomen. Given their infrequent use, direct comparisons between unilateral axillofemoral bypass (AxFB) vs cross-over femorofemoral bypass (FFB) for CLTI remain scarce. We evaluated postoperative and 5-year outcomes after AxFB vs FFB for CLTI.
METHODS: Patients undergoing nonemergent unilateral AxFB and FFB in the Vascular Quality Initiative linked to Medicare claims between 2014 and 2019 were identified, excluding procedures with other concomitant bypasses/interventions. We performed 1:2 (AxFB:FFB) propensity score matching for baseline demographics, comorbidities, urgency, ipsilateral presentation, and contralateral symptoms (rest pain vs ulcer/gangrene), and prior interventions/bypass procedures. Perioperative and 5-year outcomes were analyzed using logistic regression and Cox regression models.
RESULTS: We included 1185 patients (27% AxFB), of whom 224 AxFBs matched with 374 FFBs. After matching, perioperative mortality was comparable between the AxFB and FFB bypass groups (15% vs 10%; P = .12). However, AxFB patients had higher rates of any postoperative complication (30% vs 15%; P < .01) as well as ipsilateral major amputations (below knee, 1.8% vs 0.5%; above knee, 5.4% vs 2.4%; P = .05), in-hospital reintervention (13% vs 7.2%; P = .04), and surgical site infections (5.8% vs 1.6%; P = .01). Patency rates at discharge were similar between the two groups. Postoperative length of stay was higher in the AxFB patients (6.9 ± 5.3 vs 6.2 ± 20; P < .01), and rates for discharge to home were lower (57% vs 68%; P = .07). At 5 years, AxFB was associated with lower rates of 5-year overall survival (41% vs 46%; adjusted hazard ratio [aHR]. 1.3; 95% confidence interval [CI], 1.0-1.7; P = .046), and comparable reintervention free survival (49% vs 45%; aHR, 0.86; 95% CI, 0.59-1.2; P = .40). There was a suggestion of lower major amputation-free survival (69% vs 89%; aHR, 1.7; 95% CI, 0.92-3.1; P = .089), albeit not significantly.
CONCLUSIONS: Unilateral AxFB for CLTI was associated with lower 5-year survival rates and similar amputation-free survival and reintervention free-survival rates, alongside similar perioperative mortality and higher postoperative complication rates when compared with FFB. Our data confirm that, among the extra-anatomical bypass options, FFB remains first-line therapy and unilateral AxFB is an alternative option for the treatment of aortoiliac occlusive disease in select CLTI patients with acceptable outcomes.
