Complex Endovascular Intervention Requiring Long Operative Time Loses the Benefits of Lower Mortality and Morbidities over Open Bypass for Patients with Aortoiliac Occlusive Disease

Endovascular intervention has become the first-line therapy for aortoiliac occlusive disease because of lower operative mortality and morbidities. However, there is little data comparing the outcomes of prolonged complex endovascular procedures with those of open bypasses. In this study, we asked whether longer operative time adversely affects the outcomes of endovascular cases and at what point the long operative time negates the benefits of endovascular over open bypasses. The American College of Surgeons National Surgical Quality Improvement Program targeted Aortoiliac Endo (ENDO) and Aortoiliac Open databases (OPEN) 2011 to 2021 were used. Emergent cases were excluded. A histogram of outcomes vs operative time of ENDO showed that adverse events markedly increased after 3 hours of operative time. Based on this, we stratified ENDO into three groups (ENDO <3 hours, 3-4 hours, and >4 hours) and compared the outcomes of each group to OPEN. Studied outcomes were 30-day mortality, major adverse cardiovascular events (MACE), pulmonary, renal dysfunction, sepsis, wound complications, and length of stay. Multivariable regression analyses were used. There were 8866 OPEN and 6717 ENDO cases. The distribution of ENDO by operative time is shown in the table (Table). ENDO patients were generally sicker, more likely to be obese, use steroids, have hypertension, congestive heart failure, type 2 diabetes mellitus, bleeding disorders, chronic obstructive pulmonary disease, and be on dialysis. After adjusting for these preoperative differences on multiple regression analysis, ENDO under 3 hours had the most benefits over OPEN: lower mortality (adjusted odds ratio [aOR], 0.415; P < .0001), MACE (aOR, 0.285; P < .0001), pulmonary events, and others (Table). However, ENDO between 3 and 4 hours no longer had superior outcomes in mortality and MACE. When the operative time was longer than 4 hours, all benefits over OPEN were lost except for shorter length of stay. Performing endovascular intervention first over open is still sensible for aortoiliac occlusive disease when it is done in an operative time of under 3 hours, but the benefits of lower operative mortality and morbidities over open bypasses are lost if the operative time is over 4 hours. Given the known superior long-term outcomes of open bypasses for aortoiliac occlusive disease, this operation should be considered if endovascular intervention is anticipated to be complex and require more than 4 hours of operative time.TableMultivariable analysis of 30-day outcomes of endovascular (ENDO) aortoiliac compared with open (OPEN) aortoiliac proceduresOPEN (n = 8866)ENDO <3 hours (n = 5838)3 hours 4 hours (n = 423)No. (%)No. (%)aOR vs OPEN (P value)No. (%)aOR vs OPEN (P value)No. (%)aOR vs OPEN (P value)Mortality2.901.230.415 (< .0001)2.850.913 (.7551)3.310.923 (.7815)MACE4.861.510.285 (< .0001)3.950.765 (.2829)5.201.000 (.9992)Pulmonary events5.291.420.256 (< .0001)3.070.514 (.0164)4.730.757 (.2392)Renal dysfunction2.030.450.219 (< .0001)0.440.183 (.0173)1.650.672 (.3109)Wound complications9.541.320.121 (< .0001)7.020.762 (.1522)9.691.018 (.9165)Sepsis3.201.180.393 (< .0001)1.320.370 (.0174)2.600.633 (.1510)VTE events0.950.380.378 (< .0001)0.880.907 (.8498)1.651.707 (.1791)LOS >7 days40.1610.450.152 (< .0001)19.960.355 (< .0001)34.040.640 (< .0001)Discharge to facility24.1615.950.580 (< .0001)20.480.667 (.0010)28.200.953 (.6805)MACE, Major adverse cardiovascular events. Open table in a new tab