Conduit choice in open repair of iliac artery injuries: a comparative analysis of in-hospital outcomes from the National Trauma Data Bank.

Abstract

Objective: Iliac artery trauma is associated with substantial morbidity and mortality. Although open bypass or patch arterioplasty remain common even in the endovascular era, associations between conduit choice and outcomes remain unclear. This study compares short-term outcomes among conduit types for iliac artery injuries in a national cohort.

Methods: Patients undergoing open patch or bypass repair of an iliac artery injury were identified from the National Trauma Data Bank (2017-2023) via deterministic, fully supervised natural language processing techniques and stratified by repair material. Reconstructions performed with entirely autogenous (vein patch or autogenous vein bypass) or cadaveric (nonautogenous tissue substitute patch or bypass used with or without autogenous vein) material were classified as such. Repairs that included any synthetic material (prosthetic patch or conduit) were classified as synthetic. The primary endpoint was the composite of in-hospital, amputation-free survival. Secondary endpoints included sepsis, surgical site infection, and reintervention rates. Cox proportional hazard modeling was used to adjust differences between groups.

Results: A total of 1014 patients were analyzed. Patients across cohorts presented with class II hemorrhagic shock and substantial injury burden, with the synthetic cohort having the highest vascular abbreviated injury scores (6.0; interquartile range [IQR],4.0-8.0 vs autogenous 5.5; IQR, 3.0-7.2; P = .04 and cadaveric 4.0; IQR, 3.0-7.0; P < .001) and rates of prehospital traumatic arrests (9% vs autogenous 3%; P = .003 and cadaveric 8%; P = .6). Compared with synthetic, autogenous reconstructions were more often performed at level 1 centers (75% vs 65%; P = .008). High rates of concomitant hollow viscous injuries occurred across cohorts, particularly with synthetic reconstructions vs autogenous (stomach/small bowel injury: 44% vs 36%; P = .03 and colon/rectal: 31% vs 24%; P = .04). In-hospital mortality rates were highest in the synthetic cohort (31% vs autogenous: 17%; P < .001; and cadaveric: 18%; P < .001). Rates of sepsis and surgical site infection were suspiciously low (consistent with prior NTDB analyses) and similar. No differences were observed in reintervention rates (median number of vascular interventions, 1; IQR, 1-2). Cox proportional hazard modeling with autogenous reconstruction as the reference cohort revealed lower rates of risk-adjusted in-hospital amputation-free survival in the synthetic cohort (hazard ratio, 1.76; 95% confidence interval, 1.26-2.46; P < .001) but not the cadaveric cohort (hazard ratio, 1.02; 95% confidence interval, 0.68-1.54; P = .913).

Conclusions: Synthetic reconstruction for iliac artery trauma demonstrated lower risk-adjusted in-hospital amputation-free survival compared with autogenous or cadaveric reconstructions. In the context of frequent hollow viscous injury, there were no differences in rates of short-term infectious complications with respect to conduit type. Although prosthetic repairs remain practical in time-sensitive trauma scenarios, autogenous and cadaveric conduits may be associated with short-term survival and limb salvage advantages.