Contemporary comparison of aortofemoral bypass to alternative inflow procedures in the Veteran population

Objective: Multiple vascular inflow reconstruction options exist for claudication, including aortofemoral bypass (AFB) and alternative inflow procedures (AIPs) such as femoral reconstruction with iliac stents, and femoral-femoral, iliofemoral, and axillofemoral bypass. Contemporary multi-institution comparison of these techniques is lacking. Methods: The Veterans Affairs Surgical Quality Improvement Project (VASQIP) national database (2005-2013) was used to compare AFB vs AIP in a propensity-matched analysis. Primary outcome was mortality at 30 and 90 days. Secondary outcomes included rates of postoperative complications. Multivariable regression assessed the adjusted effect of inflow procedure type on mortality. Results: A matched cohort of 748 claudicant patients (373 AFB, 375 AIP) was identified. The AFB and AIP groups had similar mean age (59.9 vs 60.8 years; P=.30), gender (P=.51), race (P=.52), recent smoking (79.1% vs 76.5%; P=.43), history of coronary artery disease (14.8% vs 14.7%; P>.99), chronic obstructive pulmonary disease (18.8% vs 18.4%; P=.92), renal insufficiency (5.9% vs 6.1%; P>.99), and diabetes (22% vs 20%; P=.53), and American Society of Anesthesiologists Physical Status Classification (P=.41). The AFB group had longer mean operative time (4.9 vs 3.5 hours; P<.0001), more senior resident assistants (72.4% vs 61.1%; P<.0001), and greater mean red blood cell transfusion (1.1 vs 0.12 units; P<.0001). AFB and AIP had similar rates of outflow bypass (1.9% vs 1.3%; P=.58) and outflow endovascular interventions (0.54% vs 1.6%; P=.29). AFB trended toward a higher rate of mortality at 30 days postoperatively (2.7% vs 0.8%; P=.06), but by 90 days, the crude mortality rates were similar for the two (2.9% vs 2.1%; P=.5). AFB had higher rates of pneumonia (5.9% vs 0.8%; P<.001), deep vein thrombosis/pulmonary embolism (1.3% vs 0%; P=.03), postoperative transfusion (2.7% vs 0.53%; P=.02), and urinary tract infection (3.5% vs 0.8%; P=.01), but similar rates of myocardial infarction (1.6% vs 0.8%; P=.34), stroke (0.8% vs 0%; P=.12), wound complications (13.1% vs 12.8%; P=.91), renal failure (1.1% vs 0.3%; P=.22), graft failure (1.3% vs 1.1%; P=.75), and return to the operating room (12.9% vs 9.6%; P=.17). Multivariable analysis showed AFB was not independently associated with mortality (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.1-3.0). Significant factors included age (OR, 1.2; 95% CI, 1.1-1.4), postoperative renal insufficiency (OR, 2.5; 95% CI, 1.6-4.0), and unplanned reintubation (OR, 35.5; 95% CI, 3.1-399). Conclusions: For claudicant patients with inflow disease, AFB has higher rates of 30-day complications and a trend toward higher mortality; however by 90 days postoperatively, the two procedure types have similar rates of mortality.