RS15 - Aortobifemoral Bypass Remains More Durable Long-term Compared to Endovascular Intervention for Aortoiliac Occlusive Disease: A 5-Year Analysis in the VQI-VISION Database

Objectives: Peripheral endovascular intervention (PVI) has become a first-line treatment for aortoiliac occlusive disease (AIOD). While short- and mid-term data for PVI is strong, evaluation of long-term comparative efficacy, durability, and safety of these interventions compared to aortobifemoral bypass (ABF) has not been well studied beyond single-institutional experiences.

Methods: Vascular Quality Initiative datasets were queried for de novo aortoiliac interventions (ABF or suprainguinal PVI) and linked to Medicare claims from 2010 to 2019. Emergent cases and interventions for aneurysm or dissection were excluded. Primary outcome was 5-year estimates of freedom from major adverse limb events (MALE: major amputation or reintervention) or death. Secondary outcome was freedom from major amputation or death. Kaplan-Meier (KM) analysis compared outcomes between patients undergoing ABF vs PVI. Adjusted analysis was performed using Cox regression. Subgroup analysis compared patients presenting with chronic limb threatening ischemia (CLTI) versus claudication.

Results: 4,282 cases were identified: 931 ABF (21.7%) and 3,351 PVI (78.2%; 8.8% with concurrent femoral endarterectomy). Over the study period, there was a trend toward increased PVI utilization (2010-2014: 32.2%; 2015-2019: 67.8%, p=0.01). Patients undergoing PVI were more likely to be older, live in urban areas, have higher rates of cardiovascular comorbidities, and greater likelihood of presenting with claudication (68.1% vs 58.3%; p< 0.0001). Freedom from MALE or death at 5 years was 58.7% in the ABF group and 38.2% in the PVI group (p < 0.0001), Figure 1. In sequential Cox regression analysis, the observed difference in rate of MALE and death between groups favoring ABF persisted and remained significant after adjustment for covariates of known clinical significance (aHR for PVI: 1.889; 95% CI, 1.648–2.166; p< 0.0001), Table I. This remained true for patients undergoing treatment for both claudication (aHR: 1.807, 95%CI: 1.498–2.18; p< 0.001) and CLTI (aHR: 1.959, 95% CI: 1.605–2.392; p< 0.0001). Freedom from major amputation or death at 5 years was 70.5% in the ABF group and 60.1% in the PVI group (p < 0.0001). On subgroup analysis, PVI was only associated with increased risk of major amputation or death among CLTI patients (aHR: 1.665, 95%CI: 1.311–2.114; p< 0.0001), suggesting that increased MALE in patients undergoing PVI for claudication is related to increased reinterventions.

Conclusions: Despite the shift toward an endovascular-first approach for AOID, the durability of suprainguinal PVI may not persist long-term. In medically appropriate patients, ABF may offer CLTI patients improved limb preservation, while patients with claudication may experience reduced reintervention rates.