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A Propensity Matched Comparison of Hybrid Surgery and Aortobifemoral Bypass for Inflow Revascularization
Cassius Iyad Ochoa Chaar, MD, Saman Doroodgar Jorshery, MD, Jiajun Luo, MPH, Yawei Zhang, MD, MPH, PhD, Timur Sarac, MD.
Yale University School of Medicine, New Haven, CT, USA.

Objective: Aortobifemoral bypass (ABF) remains the preferred method of inflow revascularization. Recent studies have examined the outcomes of alternative inflow procedures but the outcomes of hybrid surgery (HYB) per se has not been studied. This paper compares the perioperative outcomes of ABF and HYB in a propensity matched population.
Methods: The ACS-NSQIP files were reviewed between 2012-2015. HYB revascularization via femoral to femoral bypass combined with retrograde iliac revascularization and ABF were identified based on Current Procedural Terminology codes. The patients undergoing ABF were selected via propensity matching with HYB group based on sex, race, age, American Society of Anesthesiologists (ASA) classification, indication for intervention, emergency status, functional status, and dialysis status. Patient characteristics and outcomes were compared between the 2 groups.
Results: After propensity matching, 571 patients were selected (HYB = 193, ABF = 378). Demographics and comorbidities were similar. HYB had significantly more concomitant femoral endarterectomy (P<.001) but was significantly less performed under general anesthesia (P<.001) with shorter operating time (P<.001). HYB patients had significantly lower rate of pneumonia (P<.001), unplanned intubation (0.032), cardiac arrest (0.025), and need for transfusion (P<.001). Hybrid group had superior perioperative outcomes in terms of composite morbidity (P<.001), mortality (P=.043), reoperation (P=0.009), discharge time (P<.001), and length of hospitalization (P<.001). There was no difference in major amputation or readmission between groups. (Table1)
Conclusion: In patients with similar characteristics, HYB has superior perioperative outcomes compared to ABF. The long-term outcomes of HYB surgery warrant additional research.

Table1: Detailed comparison of aortobifemoral bypass (ABF) and hybrid surgery (HYB).
ABF
(N=378)
HYB
(N=193)
P-Value
DemographicsGenderMale57.7%(218)60.6%(117).498
BMI (Mean±SD)26.43±5.81626.92±5.718.342
RaceWhite76.7%(290)76.2%(147).883
Others23.3%(88)23.8%(46)
Age Groups<7060.6%(229)58.0%(112).557
≥7039.4%(149)42.0%(81)
ComorbiditiesDiabetes23.5%(89)23.3%(45).951
Smoker64.6%(244)62.7%(121).662
Functional StatusIndependent96.0%(363)93.3%(180).147
Dependent4.0%(15)6.7%(13)
COPD22.2%(84)19.2%(37).399
CHF1.9%(7)3.1%(6).341
HTN78.0%(295)78.2%(151).957
Dialysis0.5%(2)1.6%(3).214
Open wound/Wound infection11.6%(44)14.5%(28).329
Sepsis2.4%(9)1.6%(3).759
Periprocedural DetailsTransfer fromHome94.7%(358)93.3%(180).484
Others5.3%(20)6.7%(13)
Discharge toHome79.9%(302)85.5%(165).101
Others20.1%(76)14.5%(28)
AnesthesiaGeneral99.7%(377)94.8%(183)<.001*
Others0.3%(1)5.2%(10)
Concomitant Femoral Endarterectomy 13.2% (50)29% (56)<.001*
ASA Classification ≤ 371.2%(269)70.5%(136).862
≥4 28.8%(109)29.5%(57)
IndicationIntermittent Claudication52.4%(198)48.2%(93).343
Critical Limb Ischemia47.6%(180)51.8%(100)
Emergency Case2.1%(8)3.6%(7).286
Total operation time (Mean±SD)258.15±89.40198.39±103.90<.001*
ComplicationsAny SSI7.1%(27)11.4%(22).086
Pneumonia8.7%(33)1.6%(3)<.001*
Unplanned Intubation7.7%(29)3.1%(6).032*
Pulmonary Embolism0.8%(3)0.5%(1)1.000
Progressive Renal Insufficiency0.8%(3)2.1%(4).234
Acute Renal Failure2.1%(8)0.5%(1).285
UTI2.1%(8)2.1%(4)1.000
CVA/Stroke2.1%(8)0.5%(1).285
Cardiac Arrest3.7%(14)0.5%(1).025*
MI3.4%(13)1.6%(3).285
Transfusion44.4%(168)18.1%(35)<.001*
DVT/Thrombophlebitis1.3%(5)0.5%(1).669
Sepsis Spectrum4.8%(18)2.6%(5).264
OutcomesComposite Morbidity55.0%(208)32.6%(63)<.001*
Mortality4.2%(16)1.0%(2).043*
Major amputation0.5%(2)1.0%(2).607
Reoperation17.5%(66)9.3%(18).009*
Readmission10.1%(38)11.9%(23).495
Days from Operation to Discharge (Mean±SD)9.10±10.035.08±9.08<.001*
Total length of hospital stay (Mean±SD)9.79±10.695.79±9.72<.001*


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