Outcomes of Aortobiiliac versus Aortobifemoral Bypass in Patients with Aortoiliac Occlusive Disease: A National Multi-Institutional Study.

Introduction: This study aims to evaluate perioperative and one-year outcomes of patients undergoing aortobiiliac bypass (ABIB) in comparison with aortobifemoral bypass (ABFB) for the treatment of aortoiliac occlusive disease, using data from the Vascular Quality Initiative (VQI).

Methods: All patients undergoing ABIB and ABFB bypasses (2010-2023) were queried. The primary outcome was surgical site infections (SSI). The secondary outcomes included in-hospital death, 30-day mortality, postoperative myocardial infarction, return to the operating room (RTOR), estimated blood loss (EBL) > 500 mL, transfusion, intensive care unit stay > 3 days, lower extremity ischemia, major amputation, and one-year outcomes (overall survival, limb salvage, amputation-free survival, freedom from reintervention, freedom from SSI, and patency). One-to-one propensity score matching (PSM) was utilized to balance study cohorts based on covariates.

Results: A total of 6,820 ABFB (88.2%) and 914 ABIB (11.8%) surgeries were analyzed. After PSM, all covariates were balanced in two cohorts (Absolute Standard Difference < 0.1). After PSM, 881 pairs of ABFB and ABIB were created. ABFB procedures were significantly associated with higher rates of SSI (Relative Risk [RR], 2.31; 95% confidence interval [CI], 1.21-4.39; P=0.011), RTOR for infection (RR, 4.67; 95% CI, 1.35-16.18; P=0.015), and lower rates of EBL > 500 mL (RR, 0.81; 95% CI, 0.74-0.90; P<.001), compared to ABIB procedures. At one-year, ABFB was associated with increased hazards of SSI (Hazard Ratio [HR], 3.06; 95% CI, 1.22-7.67; P=0.017) and decreased hazards of loss of patency (HR, 0.12; 95% CI, 0.03-0.51; P=0.004).

Conclusions: Patients undergoing ABIB had significantly lower rates of SSI and RTOR for infection. This is likely due to the avoidance of groin incisions. Moreover, ABFB had significantly lower rate of blood less and increased rate of loss of patency. If anatomically feasible, the ABIB configuration in aortoiliac reconstructions should be preferred to reduce the risk of infection. However, every effort should be made to maintain patency during follow-up.