Comparative Long-term Outcomes Of Patients With Aorto-iliac Occlusive Disease Treated With Endarterectomy Versus Bypass
Jesse Manunga, Jr., MD, Aleem Mirza, MD, Jason Alexander, MD, Nedaa Skeik, MD, Elliot Stephenson, MD, Senthil Jayarajan, MD, Jessica Titus, MD, Joseph Karam, MD, Xiaoyi Teng, MD, Timothy Sullivan.
Minneapolis Heart Insitute at Abbott Northwestern Hospital, Minneapolis, MN, USA.
Objective: To compare outcomes of patients with aorto-iliac occlusive disease (AIOD) limited to the common iliac territory and treated by either aortoiliac thromboendarterectomy (AIE) or aortobilateral common iliac bypass grafting (ABCIG). Methods: A single - center, retrospective analysis of prospectively collected data on consecutive patients with AIOD treated either with ABCIG or AIE at our institution between the years 2012 and 2019 was carried out. Data collected included demographics, comorbidities, indication for surgery, pre and postoperative ankle brachial indexes (ABIs), estimated blood loss (EBL), major adverse events (MAEs) and long-term patency. Study endpoint was clinical success, defined as improvement in ABIs with resolution of symptoms. Results: Thirty-three patients underwent repair for AIOD (ABCIG: 20; AIE: 13) during this time. There were more females (11 in each group, mean age of 55±7 and 58±6). Indication for surgery included disabling claudication in 19 patients, ischemic rest pain in 13 and tissue loss in 1. Patients in the AIE group had higher body mass index (30±5 vs. 26±6, p=0.06) and worse preoperative left ABIs (0.40±0.21 vs. 0.52±0.12, p=0.04). Two patients in each group required concomitant renal/mesenteric artery endarterectomy. One patient in the AIE group required bilateral femoral artery exposure and external iliac thrombectomy. MAEs (4 vs.0) were higher in the ABCIB group including, pneumonia in one patient, myocardial infarction in another and return to the operating room for evacuation of hematoma in one and bypass graft declotting with lower extremity angiography in the other. There were no differences in EBL, intensive care unit or hospital length of stay between groups. One patient in the AIE group developed a superficial wound infection treated with oral antibiotics. All patients achieved return of normal ABI and complete resolution of their symptoms. At mean follow up time of 43.4±25.2 and 52.9±35.4 months in the AIE group and ABCIB group, respectively, there were no return of symptoms or need for reintervention while two patients in the ABCIB group died of non-aortic related issues. Controlling for preoperative ABIs, age and gender, improved survival was seen in the AIE group [HR 3.03 (1.19, 7.75), p=0.02]. Conclusion: Both procedures were safe, effective and conferred high long-term primary patency with no need for reintervention in patients with aortoiliac occlusive disease limited to the common iliac arteries.
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