Aortobifemoral Bypass Remains More Durable Long-term Compared to Endovascular Intervention for Aortoiliac Occlusive Disease.

Abstract

Peripheral endovascular intervention (PVI) has become a first-line treatment for aortoiliac occlusive disease (AIOD). While short- and mid-term data for PVI is strong, long-term comparative efficacy and durability of these interventions compared to aortobifemoral bypass (ABF) have not been well studied beyond single-institutional experiences. Vascular Quality Initiative (VQI) datasets were queried for de novo aortoiliac interventions (ABF or suprainguinal PVI) and linked to Medicare claims (2010-2019) (VQI-VISION). Emergent cases were excluded. Primary outcome was 5-year estimates of major adverse limb event-free survival (MALE-FS; freedom major amputation, reintervention or death). Secondary outcomes were 5-year estimates of major amputation-free survival (AFS; freedom from major amputation or death), reintervention-free survival (RFS; freedom from reintervention or death), and survival. Kaplan-Meier (KM) analysis compared outcomes between ABF versus PVI. Adjusted analysis was performed using Cox regression. Subgroup analysis compared patients presenting with chronic limb threatening ischemia (CLTI) versus claudication. We identified 4,282 cases, including 931 ABF (21.7%) and 3,351 PVI (78.2%; 8.8% with concurrent femoral endarterectomy). Overall, there was increased PVI utilization (2010-2014: 32.2%; 2015-2019: 67.8%, P=0.011). Patients undergoing PVI were more likely to be older, live in urban areas, have higher rates of comorbidities, and present with claudication (68.1% vs 58.3%; P<0.001). Five-year MALE-FS was 58.7% in the ABF group and 38.2% in the PVI (P<0.001). The difference in rates of MALE and death favoring ABF persisted in adjusted analysis (aHR: 0.544; 95% CI, 0.474-0.626; P<0.001). This remained true for patients treated for both claudication (aHR: 0.562; 95% CI: 0.466-0.679; P<0.001) and CLTI (aHR: 0.532; 95% CI: 0.434-0.652; P<0.001). Five-year AFS was 70.5% among patients undergoing ABF and 60.1% among PVI patients (P<0.001), while RFS was 59.0% and 38.4%, respectively (P<0.001). Survival was also greater with ABF among patients presenting with CLTI (66.4% vs. 44.6%; P<0.001). On subgroup analysis, ABF was independently associated with reduced risk of major amputation or death only among CLTI patients (aHR: 0.681; 95%CI, 0.533-0.870; P=0.002). There was no difference in AFS between ABF and PVI in patients with claudication, suggesting the reduced MALE-FS in patients undergoing PVI for claudication is driven by higher reintervention rates. Despite a continued temporal shift toward an endovascular-first approach for AIOD, durability of suprainguinal PVI may not persist long-term. In medically appropriate patients, ABF may offer CLTI patients improved limb preservation, while patients with claudication may experience reduced rates of reintervention.