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.
| ABF (N=378) | HYB (N=193) | P-Value | |||
| Demographics | Gender | Male | 57.7%(218) | 60.6%(117) | .498 |
| BMI (Mean±SD) | 26.43±5.816 | 26.92±5.718 | .342 | ||
| Race | White | 76.7%(290) | 76.2%(147) | .883 | |
| Others | 23.3%(88) | 23.8%(46) | |||
| Age Groups | <70 | 60.6%(229) | 58.0%(112) | .557 | |
| ≥70 | 39.4%(149) | 42.0%(81) | |||
| Comorbidities | Diabetes | 23.5%(89) | 23.3%(45) | .951 | |
| Smoker | 64.6%(244) | 62.7%(121) | .662 | ||
| Functional Status | Independent | 96.0%(363) | 93.3%(180) | .147 | |
| Dependent | 4.0%(15) | 6.7%(13) | |||
| COPD | 22.2%(84) | 19.2%(37) | .399 | ||
| CHF | 1.9%(7) | 3.1%(6) | .341 | ||
| HTN | 78.0%(295) | 78.2%(151) | .957 | ||
| Dialysis | 0.5%(2) | 1.6%(3) | .214 | ||
| Open wound/Wound infection | 11.6%(44) | 14.5%(28) | .329 | ||
| Sepsis | 2.4%(9) | 1.6%(3) | .759 | ||
| Periprocedural Details | Transfer from | Home | 94.7%(358) | 93.3%(180) | .484 |
| Others | 5.3%(20) | 6.7%(13) | |||
| Discharge to | Home | 79.9%(302) | 85.5%(165) | .101 | |
| Others | 20.1%(76) | 14.5%(28) | |||
| Anesthesia | General | 99.7%(377) | 94.8%(183) | <.001* | |
| Others | 0.3%(1) | 5.2%(10) | |||
| Concomitant Femoral Endarterectomy | 13.2% (50) | 29% (56) | <.001* | ||
| ASA Classification | ≤ 3 | 71.2%(269) | 70.5%(136) | .862 | |
| ≥4 | 28.8%(109) | 29.5%(57) | |||
| Indication | Intermittent Claudication | 52.4%(198) | 48.2%(93) | .343 | |
| Critical Limb Ischemia | 47.6%(180) | 51.8%(100) | |||
| Emergency Case | 2.1%(8) | 3.6%(7) | .286 | ||
| Total operation time (Mean±SD) | 258.15±89.40 | 198.39±103.90 | <.001* | ||
| Complications | Any SSI | 7.1%(27) | 11.4%(22) | .086 | |
| Pneumonia | 8.7%(33) | 1.6%(3) | <.001* | ||
| Unplanned Intubation | 7.7%(29) | 3.1%(6) | .032* | ||
| Pulmonary Embolism | 0.8%(3) | 0.5%(1) | 1.000 | ||
| Progressive Renal Insufficiency | 0.8%(3) | 2.1%(4) | .234 | ||
| Acute Renal Failure | 2.1%(8) | 0.5%(1) | .285 | ||
| UTI | 2.1%(8) | 2.1%(4) | 1.000 | ||
| CVA/Stroke | 2.1%(8) | 0.5%(1) | .285 | ||
| Cardiac Arrest | 3.7%(14) | 0.5%(1) | .025* | ||
| MI | 3.4%(13) | 1.6%(3) | .285 | ||
| Transfusion | 44.4%(168) | 18.1%(35) | <.001* | ||
| DVT/Thrombophlebitis | 1.3%(5) | 0.5%(1) | .669 | ||
| Sepsis Spectrum | 4.8%(18) | 2.6%(5) | .264 | ||
| Outcomes | Composite Morbidity | 55.0%(208) | 32.6%(63) | <.001* | |
| Mortality | 4.2%(16) | 1.0%(2) | .043* | ||
| Major amputation | 0.5%(2) | 1.0%(2) | .607 | ||
| Reoperation | 17.5%(66) | 9.3%(18) | .009* | ||
| Readmission | 10.1%(38) | 11.9%(23) | .495 | ||
| Days from Operation to Discharge (Mean±SD) | 9.10±10.03 | 5.08±9.08 | <.001* | ||
| Total length of hospital stay (Mean±SD) | 9.79±10.69 | 5.79±9.72 | <.001* | ||
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