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Iliac Stenting Vs Crossover Femoral Bypass For Acute And Chronic Limb Ischemia
Jacob Hubbuch, B.S., Alexandra Cocca, M.D., Abagail Clark, M.D., Amber Bettis, M.A., Michael Bounds, M.D., Eric Endean, M.D., Nathan Orr, M.D., Sam Tyagi, M.D..
University of Kentucky College of Medicine, Lexington, KY, USA.

OBJECTIVES: The gold-standard for iliac revascularization is an anatomic aorto-femoral bypass. Frequently clinical situations require a faster and lower risk extra-anatomic reconstruction such as the crossover femoral bypass. Iliac stenting has emerged as an additional rapid and low-risk approach for iliac revascularization with the advantage of avoiding an extra-anatomic route. Our objective was to compare 30-day outcomes of bypass and iliac stenting in the setting of acute and chronic limb ischemia.
METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all cases of CFB and IS between 2007 and 2017. Cases were identified as intervention for either acute limb ischemia or chronic limb ischemia based off ICD 9/10 codes. Patients were propensity matched and analyzed using Pearsonís Chi-Square test. RESULTS: A total of 4,109 cases were identified, 608 being acute and 3,501 being chronic. Among acute cases, 284 patients underwent bypass and 324 underwent stenting. Bypass patients compared to stented patients for acute ischemia were more likely to develop surgical site infection (SSI) (7% vs 2%; p<0.001), receive transfusion (17% vs 10%, p=0.0124), and return to the OR (14% vs 8%; p=0.0089). These findings were confirmed by propensity matching, except transfusion. There were 1,177 chronic ischemia patients treated with bypass and 2,324 stented. Bypass had more SSI (7% vs 1%; p<0.001), sepsis (2% vs 1%; p=0.0132), major cardiac event (3% vs 2%; p=0.0014), myocardial infarction (2% vs 1%; p =0.0095), new renal insufficiency (1% vs 0%; p=0.0029), wound disruption (2% vs 0%; p<0.001), transfusion (16% vs 5%; p<0.001), pneumonia (2% vs 0%; p=0.0095), and returns to the OR (9% vs 6%; p<0.001). However, after propensity matching, only SSI, renal insufficiency, wound disruption, and transfusion were significantly different. Bypass vs stenting did not have different amputation rates in chronically ischemic patients (1% vs 0%; p=0.7259) and there were no amputations in the acute ischemia cohort. CONCLUSIONS: Crossover femoral bypass is associated with more adverse post-operative events in the management of both acute and chronic limb ischemia when compared to iliac stenting. Based on these findings our recommendations would be for a stenting approach as the primary treatment modality for unilateral iliac occlusive disease, and that crossover femoral bypass be reserved as a secondary option.


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