Aorto-bifemoral bypass versus covered endovascular reconstruction of aortic bifurcation

BACKGROUND Covered endovascular reconstruction of aortic bifurcation (CERAB) is increasingly utilized as a first line treatment in patients with aorto-iliac occlusive disease (AIOD). We sought to compare the outcomes of patients undergoing CERAB compared to the gold standard of aorto-bifemoral bypass (ABF). METHODS The Vascular Quality Initiative was queried for patients undergoing ABF or CERAB from 2009-2021. Propensity scores were generated using demographics, comorbidities, Rutherford class, and urgency. The two groups were matched using 5-to-1 nearest neighbor match. Our primary outcomes were 1-year estimates of primary patency, major adverse limb events (MALE), MALE-free survival, reintervention-free survival, and amputation-free survival. Standard statistical methods were utilized. RESULTS 3,944 ABF and 281 CERAB cases in total were identified. Of all patients with AIOD, the proportion of CERAB increased from 0% to 17.9% between 2009-2021. Compared to ABF, patients undergoing CERAB were more likely to be older (64.7 vs. 60.2; p<.001) and more often had diabetes (40.9% vs. 24.1%; p<.001) and end-stage renal disease (1.1% vs. 0.3%; P=.03). In the matched analysis (229 CERAB vs. 929 ABF), ABF patients had improved MALE-free survival (93.2% [±0.9%] vs. 83.2% [±3%]; p<.001) and lower rates of MALE (5.2% [±0.9%] vs. 14.1% [±3%]; p<.001), with comparable primary patency rates (98.3% [±0.3%] vs. 96.6% [±1%]; p=.6) and amputation-free survival (99.3% [±0.3%] vs. 99.4% [±0.6%]; p=.9). Patients in the CERAB group had significantly lower reintervention-free survival (62.5% ± [6%] vs. 92.9% ± [0.9%]; p<.001). Matched analysis also revealed shorter LOS (1 vs. 7 days; p<.001), as well as lower pulmonary (1.2% vs. 6.6%; p=.01), renal (1.8% vs. 10%; p<.001), and cardiac (1.8% vs. 12.8%; p<.001) complications among CERAB patients. CONCLUSION CERAB had lower perioperative morbidity compared to ABF with a similar primary patency 1-year estimates. However, patients undergoing CERAB experienced more major adverse limb events and reinterventions. Although CERAB is an effective treatment of patients with AIOD, further studies are needed to determine the long-term outcomes of CERAB compared to the established durability of ABF and further define the role of CEARB in treatment of AIOD.