SS20 - Covered Endovascular Reconstruction of Aortic Bifurcation Is Comparable to Aortobifemoral Bypass in Midterm Follow-up: A Multi-institutional Study from a Medicare-Linked Database

Objectives: Aortobifemoral bypass (ABFB) is the gold-standard procedure for aortoiliac occlusive disease (AIOD). Axillobifemoral bypass (AxBFB) has been traditionally used for aortoiliac reconstructions in patients who are deemed high risk for ABFB. However, in the endovascular era, covered endovascular reconstruction of aortic bifurcation (CEARB) is being used frequently in high- and standard-risk patients with AIOD. We aimed to compare the midterm outcomes of ABFB, AxBFB, and CERAB in the Vascular Quality Initiative (VQI)-Medicare-Linked database.

Methods: All patients with AIOD who underwent aortoiliac reconstruction by ABFB, AxBFB or CERAB during 2009-2019 in VQI-Medicare-Linked database were included. The primary outcome was amputation-free survival (AFS). The secondary outcomes were overall survival (OS), freedom from reintervention (FFR) and limb salvage (LS). Outcomes were assessed in one- and three-years. Kaplan-Meier estimates and COX-regression were used for the analyses.

Results: Three cohorts of patients undergoing ABFB (N=2,271, 61.8%), AxBFB (N=1,226, 33.4%) and CERAB (N=178, 4.8%) were studied. The patients in AxBFB and CERAB cohorts were older than the ABFB cohort (71.3±9.3, 69.9±9.7 and 65.6±7.7, respectively; P< 0.001) and were more likely to have comorbidities compared to their ABFB counterparts. One-year and three-years AFS were 90.3%, 73.7%, 87.7% and 79.7%, 55.2%, 66.4% in ABFB, AxBFB and CERAB cohorts, respectively (P < 0.001, Figure I). After adjusting for potential confounders, AxBFB was associated with greater hazards of major amputation or death compared to ABFB at three-years (aHR=1.62, 95%CI=1.33-1.98; P< 0.001) but CERAB was not (aHR=1.42, 95%CI=0.95-2.10; P=0.084). Three-years FFR was 85.5%, 83.8% and 77.0% in ABFB, AxBFB and CERAB cohorts, respectively (P=0.015). After adjusting for potential confounders, CERAB was not associated with increased risk of reintervention at one-year compared to ABFB (aHR=1.27, 95%CI=0.74-2.16; P=0.388). However, at three-years, CERAB was associated with increased hazards of reintervention compared to ABFB (aHR=1.87, 95%CI=1.31-2.67; P=0.001). CERAB was also associated with lower hazards of major amputation or death at one-year compared to AxBFB (aHR=0.59, 95%CI=0.35-0.99; P=0.045) but not at three-years (Table I).

Conclusions: We found that CERAB is comparable to ABFB in three-years in terms of OS, LS and AFS, albeit with substantial increase in reintervention rate. AxBFB had worse OS, LS and AFS compared to ABFB. CERAB was associated with higher AFS compared to AxBFB. This national contemporary study supports the use of CERAB as a safe and efficient alternative to ABFB and AxBFB in high surgical risk patients. However, further prospective studies are necessary to confirm our findings.