Contemporary ten-year outcomes for aorto-bifemoral bypass in the endovascular era

Abstract

Background:The recently described "Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB)" technique challenges the role of open surgical bypass in the treatment of aorto-iliac occlusive disease. Complications and mortality after aortobi-femoral bypass have remained stable over the last three decades despite declining caseloads but there are few contemporary outcomes to enable direct comparison. We present 10 years of consecutive patients treated with aorto-bi-femoral bypass at a single tertiary centre.Methods: A retrospective review was performed of prospectively maintained operating theatre logbooks. Notes were reviewed to ascertain the indication for surgery in addition to demographic data. Cross-sectional pre-operative imaging was reviewed to determine the extent of the disease according to the TASC-II classification. Primary endpoints were graft patency and survival. Secondary endpoints were reinterventions, immediate and delayed complications. Results: Between 2004 and 2015, 185 patients (61% male) with peripheral vascular disease (51% Fontaine Class 2b, 25% Class 3, 21% Class 4) were treated. The median age was 62 years (range 37-82). 58% were current smokers, 41% ex-smokers. 26% had undergone previous attempts at treatment (42/49 by endovascular means). Lesion morphology characterised by CT angiography included 1 TASC-II A, 9 TASC-II B, 25 TASC-II C and 97 TASC-II D lesions. Median follow up was 67 months. Thirty-day mortality was 4.3%. There were 28 major complications (15%), including 7 early limb occlusions requiring reintervention. Patency was 94% at 1 year, 88% at 3 years, 82% at 5 years and 79% at 10 years. In 31% of cases the limbs of the graft were landed distal to the common femoral artery. To date there have been 9 cases of graft infection, 5 requiring explantation. Survival was 94%, 81% and 64% at 1, 5 and 10 years respectively. Conclusions: Open surgery cannot compete with low 30-day morbidity and mortality rates reported with endovascular techniques. However, patency in our series exceeds much of the historical literature for this procedure despite the graft landing distal to the common femoral artery in one third of patients. Comparing our data to the available 1 and 2-year CERAB patency rates, our rates exceed endovascular patency by over 5% at both 1 and 3 years. Secondary patency for CERAB can be obtained but longer-term follow-up for endovascular techniques have yet to be reported. The "Gold Standard" remains a subject for debate.