Outcomes following unilateral axillofemoral bypass versus crossover femorofemoral bypass in chronic limb-threatening ischemia patients

Abstract

Objective

In patients with chronic limb-threatening ischemia (CLTI), extra-anatomical bypasses are viable options to establish inflow when aortic cross-clamping necessary for anatomical reconstruction cannot be tolerated or in those with a hostile abdomen. Given their infrequent use, direct comparisons between unilateral axillofemoral bypass (AxFB) vs cross-over femorofemoral bypass (FFB) for CLTI remain scarce. We evaluated postoperative and 5-year outcomes after AxFB vs FFB for CLTI.

Methods

Patients undergoing nonemergent unilateral AxFB and FFB in the Vascular Quality Initiative linked to Medicare claims between 2014 and 2019 were identified, excluding procedures with other concomitant bypasses/interventions. We performed 1:2 (AxFB:FFB) propensity score matching for baseline demographics, comorbidities, urgency, ipsilateral presentation, and contralateral symptoms (rest pain vs ulcer/gangrene), and prior interventions/bypass procedures. Perioperative and 5-year outcomes were analyzed using logistic regression and Cox regression models.

Results

We included 1185 patients (27% AxFB), of whom 224 AxFBs matched with 374 FFBs. After matching, perioperative mortality was comparable between the AxFB and FFB bypass groups (15% vs 10%; P = .12). However, AxFB patients had higher rates of any postoperative complication (30% vs 15%; P < .01) as well as ipsilateral major amputations (below knee, 1.8% vs 0.5%; above knee, 5.4% vs 2.4%; P = .05), in-hospital reintervention (13% vs 7.2%; P = .04), and surgical site infections (5.8% vs 1.6%; P = .01). Patency rates at discharge were similar between the two groups. Postoperative length of stay was higher in the AxFB patients (6.9 ± 5.3 vs 6.2 ± 20; P < .01), and rates for discharge to home were lower (57% vs 68%; P = .07). At 5 years, AxFB was associated with lower rates of 5-year overall survival (41% vs 46%; adjusted hazard ratio [aHR]. 1.3; 95% confidence interval [CI], 1.0-1.7; P = .046), and comparable reintervention free survival (49% vs 45%; aHR, 0.86; 95% CI, 0.59-1.2; P = .40). There was a suggestion of lower major amputation-free survival (69% vs 89%; aHR, 1.7; 95% CI, 0.92-3.1; P = .089), albeit not significantly.

Conclusions

Unilateral AxFB for CLTI was associated with lower 5-year survival rates and similar amputation-free survival and reintervention free-survival rates, alongside similar perioperative mortality and higher postoperative complication rates when compared with FFB. Our data confirm that, among the extra-anatomical bypass options, FFB remains first-line therapy and unilateral AxFB is an alternative option for the treatment of aortoiliac occlusive disease in select CLTI patients with acceptable outcomes.