Print this pageA Personal Experience with Direct Reconstruction and Extra-anatomic Bypass for Aorto-iliofemoral Occlusive Disease
Norman R. Hertzer, MD, (Emeritus), James F. Bena and Mathew T. Karafa, Ph.D.
Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
Objective: To investigate factors influencing the outcome of all open operations for aorto-iliofemoral occlusive disease that were performed by a single surgeon at a tertiary referral center from 1976-2002.
Methods: The series includes 355 direct reconstructions and 181 extra-anatomic bypass (EAB) grafts in 339 men (63%) and 197 women with median ages of 61 and 62 years, respectively. These procedures were done for claudication alone in 267 patients (50%), for advanced ischemia in 258 (48%), and to facilitate other interventions in 11 (2.0%). Patients receiving EAB were older (P<.001) and more likely to have advanced limb ischemia (P<.001), superficial femoral artery occlusions (P<.001), prior inflow operations (P<.001), elevated creatinine levels (P=.017) and severe obstructive pulmonary disease (P=.016). Survival and patency analysis was performed using logistic regression, Kaplan-Meier estimations and Cox proportional hazards models.
Results: Procedures and selected univariable outcomes are summarized in the following table:
| Index Procedure |
Patients (Limbs) |
Op Mortality (%) |
Odds Ratio for Op Mortality (95% CI) |
Late Survival (%) |
Hazard Ratio for Late Death (95% CI) |
Late Graft Patency (%) |
Hazard Ratio for Graft Occlusion (95% CI) | ||
| 5 yrs | 10 yrs | 5 yrs | 10 yrs | ||||||
| Direct | 355 (673) |
2.3 | 1.0 P<.001 vs. EAB |
70 | 45 | 1.0 P<.001 vs. EAB |
85 | 77 | 1.0 P<.001 vs. EAB |
| Aortofem | 255 (510) |
1.2 | 1.0 P=.085 vs. AIB/iliofem |
70 | 44 | 1.0 P=.079 vs. AIB/iliofem |
88 | 81 | 1.0 P=.44 vs. AIB/iliofem |
| Aortoiliac | 54 (108) |
5.6 | 4.9 (0.97-2.5) |
78 | 53 | 0.75 (0.52-1.1) |
92 | 82 | 0.66 (0.28-1.6) |
| Iliofem | 46 (55) |
4.4 | 3.8 (0.62-6.9) |
60 | 42 | 1.2 (0.92-1.6) |
91 | 86 | 1.4 (0.56-3.6) |
| EAB | 181 (257) |
8.8 | 4.2 (1.8-10) |
51 | 27 | 1.7 (1.4-2.2) |
76 | 60 | 3.7 (2.4-5.6) |
| Femfem | 90 (90) |
5.6 | 1.0 P=.12 vs. axfem |
68 | 35 | 1.0 P<.001 vs. axfem |
80 | 57 | 1.0 P=.47 vs. axfem |
| Axfem | 91 (167) |
12 | 2.3 (0.78-7.0) |
34 | 18 | 2.4 (1.6-3.6) |
74 | 66 | 1.3 (0.68-2.3) |
On multivariable analysis, EAB had a higher incidence of postoperative death (8.8% vs. 2.3%, P=.005) or graft thrombosis (8.8% vs. 2.8%, P=.006). Women were more likely to sustain graft thrombosis (p=.006) or require major amputation (P=.050) during the early postoperative period. Overall late survival rates (87±3% at 1 year, 64±5% at 5 years, 39±5% at 10 years and 20±4% at 15 years) were stratified as shown in Figure 1:
Late survival rates were significantly lower (P=.026) after EAB and also were unfavorably associated with advanced preoperative ischemia (P=.046) and with medical co-morbidities (P<.001). Overall late patency rates (95±2% at 1 year, 85±3% at 5 years, 77±5% at 10 years and 69±7% at 15 years) were stratified as shown in Figure 2:
Late graft occlusions occurred more frequently with a history of prior inflow procedures (P=.028) and were especially common after EAB (P<.001). Patients over 65 years of age had worse early and late mortality rates (P<.001), but younger patients had a higher overall risk for graft thrombosis (P<.001) or major amputation (P<.001).
Conclusions: The higher operative mortality rate and lower late survival for EAB in this series largely were preordained by the frequent selection of EAB for patients who represented poor medical risks for direct reconstruction. However, the durability of aortofemoral, aortoiliac or iliofemoral bypass compared to either femorofemoral or axillofemoral bypass makes direct reconstruction clearly superior for average or low-risk patients. Direct reconstruction should be used preferentially in such cases, especially in women and in younger patients of either gender.