Proximal Anastomosis Configuration and Aortobifemoral Bypass Outcomes

Aortobifemoral bypass (ABF) for the management of aortoiliac occlusive disease has a reported primary patency over 80% at 5 years. Little is known about how the proximal ABF anastomosis configuration (pABF) relates to patency over time. We hypothesize that end-to-side (E-S) pABF is associated with increased risk of loss of patency during follow-up (compared to end-to-end [E-E]). We examined all patients who underwent ABF within the Vascular Quality Initiative (VQI) between 2009-2023. We excluded emergent ABF, concomitant aneurysmal disease, and those without documented long-term ABF patency. The exposure of interest was pABF. The primary outcome of interest was loss of patency and secondary outcome was mortality, both at 30 days and at long-term follow-up (LTFU). Cox proportional hazards regression was utilized to determine the association between pABF and outcomes of interest. Among 5294 patients (mean age, 60.1 ± 8.6 years), 51.0% (n=2699) were treated for claudication. Nearly one-half of the cohort had an E-E pABF (50.4%; n = 2668). There was notable pABF variation among VQI regions (Fig 1). Compared to the E-S cohort, the E-E cohort was older, more likely female, more likely White, and lived in urban (vs rural) locations (Table I). The E-E cohort was less likely to be insured with Medicaid and have diabetes mellitus and chronic obstructive pulmonary disease. There were no differences in smoking or dialysis status. The two groups did not differ on use of optimal medical therapy preoperatively or at LTFU. The E-E cohort had a higher estimated blood loss (600 mL vs 500 mL; P < .001) and utilized Dacron conduits more often than the E-S cohort (83.2% vs 77.4%; P < .001). Postoperatively, the E-E cohort had longer length of stay (in days) (7 vs 6; P = .041), higher rate of postoperative renal complications (11.0% vs 7.8%; P = .041), and were more likely to be discharged to rehab vs home (12.6% vs 9.0%; P < .001). E-S pABF is associated with lower patency at LTFU on unadjusted analysis (HR, 0.5; 95% CI, 0.4-0.7) as well as adjusted analysis (aHR, 0.6; 95% CI, 0.4-0.9). There is no difference in 30-day or LTFU mortality between groups (HR, 1.0; 95% CI, 0.8-1.3 and HR, 1.1; 95% CI, 0.8-1.3, respectively). E-E pABF configuration is associated with improved patency compared to E-S pABF. Determining clinical scenarios, such as bilateral external iliac artery occlusion, where an E-S pABF is a more reasonable approach, may be of benefit to improve the long-term patency of ABF, nationally.TableBaseline characteristics among those who undergo end-to-side vs end-to-end proximal anastomosis of aortobifemoral bypass within the Vascular Quality InitiativeVariablesTotal (N = 5294)End-to-side (n = 2626)End-to-end (n = 2668)P-valueSociodemographic factorsAge (categorical), years ≤49532 (10.0)277 (10.5)255 (9.6)<.001 50-643063 (57.9)1587 (60.4)1476 (55.3) 65-791667 (31.5)747 (28.4)920 (34.5) ≥8032 (0.6)15 (0.6)17 (0.6)Rural urban commuting area Urban3900 (73.7)1882 (71.7)2018 (75.6).004 Rural1260 (23.8)675 (25.7)585 (21.9) Unavailable134 (2.5)69 (2.6)65 (2.4)Median Area Deprivation Index 0-19374 (7.1)196 (7.5)178 (6.7)<.001 20-39725 (13.7)307 (11.7)418 (15.7) 40-591348 (25.5)655 (24.9)693 (26.0) 60-791484 (28.0)735 (28.0)749 (28.1) ≥801225 (23.1)662 (25.2)563 (21.1) Unknown138 (2.6)71 (2.7)67 (2.5)Gender Male3112 (58.8)1580 (60.2)1532 (57.4).042 Female2182 (41.2)1046 (39.8)1136 (42.6)Race White4632 (87.5)2235 (85.1)2397 (89.8)<.001 African American471 (8.9)285 (10.9)186 (7.0) Asian32 (0.6)13 (0.5)19 (0.7) Other/Unknown159 (3.0)93 (3.5)66 (2.5)Insurance Commercial2172 (41.0)1076 (41.0)1096 (41.1).002 Medicare/Medicare Advantage1619 (30.6)795 (30.3)824 (30.9) Medicaid650 (12.3)363 (13.8)287 (10.8) Other853 (16.1)392 (14.9)461 (17.3)Living status Home5237 (99.2)2601 (99.2)2636 (99.2).471 Nursing home25 (0.5)10 (0.4)15 (0.6) Homeless17 (0.3)10 (0.4)7 (0.3)ComorbiditiesObese -1128 (21.3)571 (21.7)557 (20.9).742ASA class 1-34234 (80.1)2104 (80.2)2130 (80.0).836 4-51054 (19.9)520 (19.8)534 (20.0)Smoker Current3403 (64.3)1658 (63.1)1745 (65.4).218 Former1798 (34.0)919 (35.0)879 (32.9) Never93 (1.8)49 (1.1)44 (1.6)Diabetes Insulin474 (9.0)262 7(10.0)212 (7.9).032 Medical therapy844 (15.9)419 (16.0)425 (15.9)Hypertension4209 (79.6)2074 (79.1)2135 (80.1).375Coronary artery disease1167 (22.0)600 (22.8)567 (21.3).161Congestive heart failure352 (6.6)169 (6.4)183 (6.9).536COPD On oxygen68 (1.3)34 (1.3)34 (1.3).017 Medical Treatment1615 (30.5)849 (32.3)766 (28.7)Preoperative dialysis On dialysis11 (0.2)4 (0.2)7 (0.3).679 Functioning transplant2 (0.0)1 (0.0)1 (0.0)Preoperative ambulation Ambulates freely4556 (86.2)2250 (85.7)2306 (86.6).498 Ambulates with prosthesis/assistance637 (12.0)323 (12.3)314 (11.8) Wheelchair/bedridden95 (1.8)52 (2.0)43 (1.6) Open table in a new tab