Even When It Fails, Endovascular Therapy Better First-Line Treatment than Surgery for Aortoiliac Disease

Download this article's Factoid in PDF (& PPT for Gold Subscribers)

Some studies have suggested that patients undergoing infrainguinal bypass surgery after failed endovascular therapy for aortoiliac disease have worse outcomes than those originally treated with surgical bypass. But a retrospective analysis challenges that assumption by showing that a secondary open procedure actually produces better outcomes than proceeding straight to surgery.

The results, published online September 17, 2012, ahead of print in the Archives of Surgery, were originally presented in February 2012 at the annual meeting of the Pacific Coast Surgical Association in Napa Valley, CA.

For the study, Erica L. Mitchell, MD, of Oregon Health and Science University (Portland, OR), and colleagues reviewed data from 188 patients with symptomatic aortoiliac occlusive disease who underwent primary open surgery (n = 153) or secondary surgery for failed endovascular therapy (n = 35) at the Portland Veterans Affairs Medical Center (Portland, OR) from January 1998 through March 2010. Types of aortoiliac reconstruction included aortobifemoral, axillobifemoral, and femoral-femoral bypass.

Higher Survival for Secondary vs. Primary Procedures

The mean postoperative change in ankle-brachial index was similar between the primary and secondary operation groups (0.29 and 0.27, respectively; P = 0.77).

At 2 and 5 years, Kaplan-Meier analyses showed that mean survival was higher in the group undergoing secondary surgery after failed endovascular treatment rather than primary surgery (table 1).

Table 1. Overall Survival

^a P = 0.01 for difference.

In addition, patients in the primary surgery group required 7 limb amputations (4.6%) by 3-year follow-up. No amputations occurred in the secondary group.

Pairwise comparison between operation types showed that survival after aortobifemoral bypass was longer than after femoral-femoral bypass, which in turn offered longer survival than axillobifemoral bypass (P < 0.05 for all comparisons).

Multivariate analyses found that decreased survival was associated with diabetes (HR 1.91; 95% CI1.16-3.13), chronic renal insufficiency (HR 2.87; 95% CI 1.32-6.23), and axillobifemoral bypass (HR 3.14; 95% CI 1.73-5.69; all P ≤ 0.01), while improved survival was associated with secondary operations (HR 0.43; 95% CI 0.20-0.94; P = 0.03).

When Failure Might Be an Option

The analysis stands in contrast to the multicenter, randomized BASIL trial and the Vascular Study Group of New England study, both of which found that patients undergoing infrainguinal bypass after failed angioplasty have worse outcomes than those treated with initial bypass.

But according to Dr. Mitchell and colleagues, several factors could explain their finding of better survival in the secondary operation group. Patients were not randomized, so those in the secondary operation group may have been more robust overall, since 80% were suitable candidates for an aortic-based procedure compared with only 44% of those who underwent primary surgery. Still another issue is that more patients in the secondary group were taking aspirin, statins, and clopidogrel at the time of operation, which may have conferred a survival benefit.

In addition, the authors point out that the study cohort was comprised of patients from a VA hospital and, as such, 97.4% were men. “The fact that their 5-year mortality approached 50% may reflect their indication for intervention, with more than 50% of patients presenting with [critical limb ischemia], as well as a host of social, economic, burden of disease, and compliance issues. . . . Therefore, although the data shown here cannot be directly extrapolated to all vascular surgery practices, the outcomes of our patients are likely no worse than the outcomes expected in a community-based practice,” they write.

‘Endo First’ Strategy: At the Least, Not Worse

In an editorial accompanying the study, Jason T. Lee, MD, of Stanford University Medical Center (Stanford, CA), concludes that “one of the take-away messages of this article is that secondary open conversion after failed [aortoiliac occlusive disease] endovascular treatment is at least not worse.”

According to Dr. Lee, the study “provides compelling evidence that for inflow disease, endovascular interventions should be the preferred initial route.

“In terms of patency, durability, patient comfort, and physician comfort, iliac stenting is at least as good as, if not better than, aortofemoral bypass,” he writes. “We now have evidence that, even if there is some fear of long-term consequences from iliac stenting should it fail, the open conversion is not worse than initial primary open operations.”

Not only is the ‘endo-first’ approach justified in these patients, Dr. Lee observes, “but many times an endo-second and endo-third, approach for [aortoiliac occlusive disease] is justified for most patients, and this strategy, even if it fails, is not hurting patients or their long-term outcomes.”

 

---

Sources
1. Danczyk RC, Mitchell EL, Petersen BD, et al. Outcomes of open operation for aortoiliac

occlusive disease after failed endovascular therapy. Arch Surg. 2012;147:841-845.

2. Lee JT. Could the endo-first strategy really be better? Arch Surg. 2012;147:846.

 

 

Related Stories:

• Endovascular Intervention Generally Safe in Elderly PAD Patients
• PCI for PAD Grows as Surgery Declines: A Boon for Patients?
• Endovascular Approach Compares Well with Surgery for Aorto-Iliac Disease