Aorto-bifemoral Bypass Versus Covered Endovascular Reconstruction Of Aortic Bifurcation: A Propensity Score Matched Study
Dana B. Semaan, MD1, Salim G. Habib, MD1, Othman M. Abdul-Malak, MD1, Jeffrey J. Siracuse, MD MBA2, Michael C. Madigan, MD1, Karim M. Salem, MD1, Rabih A. Chaer, MD MS1, Mohammad H. Eslami, MD MPH1.
1University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2Boston Medical Center, Boston, MA, USA.
OBJECTIVES: Covered endovascular reconstruction of aortic bifurcation (CERAB) is increasingly utilized as a first line treatment in patients with aorto-iliac occlusive disease (AIOD). We sought to compare the outcomes of patients undergoing CERAB compared to the gold standard of aorto-bifemoral bypass (ABF).
METHODS: The Vascular Quality Initiative was queried for patients undergoing ABF or CERAB from 2009-2021. Propensity scores were generated using demographics, comorbidities, Rutherford class, and urgency. The two groups were matched using 5-to-1 nearest neighbor match. Our primary outcomes were primary patency (PP), major adverse limb events (MALE) [vascular re-intervention, above-ankle amputation], and MALE-free survival at one year. Secondary outcomes were length of stay (LOS) and post-operative complications. Standard statistical methods were utilized.
RESULTS: 3,944 ABF and 281 CERAB cases in total were identified. Of all patients with AIOD, the proportion of CERAB increased from 0% to 17.9% between 2009-2021 (p<.001). Compared to ABF, patients undergoing CERAB were more likely to be older (64.7 vs. 60.2; p<.001) and more often had diabetes (40.9% vs. 24.1%; p<.001) and end-stage renal disease (1.1% vs. 0.3%; P=.03). ABF patients had improved MALE-free survival (93.3% [±0.004] vs. 83.7% [±0.03]; p<0.001) and lower rates of MALE (5.7% [±0.004] vs. 14.1% [±0.03]; p<0.001), with comparable PP rates (98.3% [±0.003] vs. 96.6% [±0.015]; P=.14). Matched analysis (229 CERAB vs. 929 ABF) revealed shorter LOS (2.1 vs. 8.8 days; p<0.001), as well as lower pulmonary (1.2% vs. 6.6%; P=0.007), renal (1.8% vs. 10%; p<0.001), and cardiac (1.8% vs. 12.8%; p<0.001) complications among CERAB patients with comparable PP rates between the two groups at 1 year (ABF: 98.3% [±0.005] vs. CERAB:97.3% [±0.015]; P=0.57) (Figure 1). In the matched group, ABF 1-year MALE were lower with significantly better MALE-free survival at 1 year among ABF patients compared to CERAB (Figure 1).
CONCLUSIONS: CERAB had lower perioperative morbidity compared to ABF with a similar primary patency at 1 year. However, patients undergoing CERAB experienced more major adverse limb events at 1 year. CERAB is an effective treatment of patients with AOID, further studies are needed to determine the long-term outcomes of CERAB compared to the established durability of ABF. 
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