Hybrid surgery for bilateral lower extremity inflow revascularization

Abstract

Objective: Aortobifemoral (ABF) bypass is the preferred method of bilateral inflow revascularization, with axillobifemoral (AXBF) bypass reserved for high-risk patients. Hybrid (HYB) surgery in the form of femorofemoral bypass and retrograde endovascular aortoiliac intervention is increasingly being used to achieve the same goal. This study compared the perioperative outcomes of HYB surgery with traditional surgery for bilateral inflow revascularization.

Methods: The American College of Surgeons National Surgical Quality Improvement Program files for the years 2012 to 2015 were reviewed, and all patients undergoing ABF bypass, AXBF bypass, and HYB surgery (femoral-femoral bypass and retrograde endovascular intervention) were included. Patients' demographics, comorbidities, and outcomes were compared between the three groups. A propensity-matched analysis was subsequently performed to compare HYB surgery with ABF bypass only. The χ² test and analysis of variance with post hoc analysis were conducted to evaluate between-group differences in risk factors and outcomes. SPSS statistical software (IBM Corp, Armonk, NY) was used.

Results: There were 1426 patients (ABF bypass, 976; AXBF bypass, 257; HYB surgery, 193). There were significant differences in the three populations of patients, with ABF bypass patients significantly more likely to have age <70 years (ABF bypass, 84.2%; AXBF bypass, 49.8%; HYB surgery, 58%; P < .001) and more likely to be independent (ABF bypass, 98%; AXBF bypass, 89.1%; HYB surgery, 93.2%; P < .001). Patients undergoing AXBF bypass were significantly more likely to be treated for critical limb ischemia (ABF bypass, 46.5%; AXBF bypass, 72.4%; HYB surgery, 51.8%; P < .001) under emergent conditions (ABF bypass, 0.9%; AXBF bypass, 5.1%; HYB surgery, 3.6%; P < .001). There was no difference in mortality between the three groups (P = .178). After propensity matching, a total of 571 patients with ABF bypass were compared with HYB surgery patients. HYB surgery patients had significantly less pneumonia (ABF bypass, 8.7%; HYB surgery, 1.6%; P < .001), unplanned intubation (ABF bypass, 7.7%; HYB surgery, 3.1%; P = .032), cardiac arrest (ABF bypass, 3.7%; HYB surgery, 0.5%; P = .025), transfusion (ABF bypass, 44.4%; HYB surgery, 18.1%; P < .001), and composite morbidity (ABF bypass, 55%; HYB surgery, 32.6%; P < .001). Patients undergoing ABF bypass had significantly higher mortality (ABF bypass, 4.2%; HYB surgery, 1%; P = .043) and 30-day reoperation (ABF bypass, 17.5%; HYB surgery, 9.3%; P = .009) and longer total hospital length of stay (ABF bypass, 9.79 ± 10.69 days; HYB surgery, 5.79 ± 9.72 days; P < .001). There was no difference in major amputation (P = .607) and readmission (P = .495) between the two groups.

Conclusions: ABF bypass is the most common surgery for bilateral lower extremity revascularization in the American College of Surgeons National Surgical Quality Improvement Program database and continues to have good outcomes. In selected patients, HYB surgery was associated with improved perioperative, 30-day outcomes compared with ABF bypass.

Keywords: Aortobifemoral bypass; Aortoiliac disease; Hybrid surgery; Peripheral artery disease.