Comparative outcomes of aortobifemoral bypass with or without previous endovascular kissing stenting of the aortoiliac bifurcation

Objective The aim of this multicenter national study was to compare the outcomes of primary open surgery (OS) by aortobifemoral bypass (ABFB) with those performed after a failed endovascular treatment (EVT) by Kissing Stent (KS) technique for complex aortoiliac occlusive disease (AIOD) lesions (TASC II C and D). Methods All consecutive ABFB cases carried out at twelve vascular surgery centers between 2016 and 2021 were retrospectively collected and analyzed. Data included patients’ baseline demographics and clinical characteristics, procedural details, peri-operative outcomes, and follow-up results (survival, patency, amputation). The study cohort was divided in two groups based on indications for ABFB: primary treatment vs secondary treatment after EVT failure. Results Overall, 329 patients underwent ABFB during the study period (71% males, mean age 64 years), of which 285 as primary treatment and 44 after prior EVT. At baseline, no significant differences were found between study groups in demographics and clinical characteristics. TASC C and D lesions were similarly represented in the study groups (TASC C: 22% vs 78%; TASC D: 16% vs 84%). No major differences were found between study groups in terms of procedural details, early mortality, and peri-operative complications. At five years, primary patency rates were significantly higher for primary ABFB (88%, CI 93.2%-84%) as compared to ABFB after prior EVT (69%, CI 84.9%-55%, log rank p value <.001); however, the five-year rates of secondary patency (100% vs 95% CI 100%-86%) and limb salvage (97%, CI 99%-96 vs 97%, CI 100%-94%) were similar between study groups. Conclusions Surgical treatment of TASC C/D AIOD with ABFB seems to be equally safe and effective when performed after prior EVT, although primary ABFB seemed to have higher primary patency rates. Despite the need for more frequent reinterventions, secondary patency and limb salvage rates were similar. However, future large prospective trials are required to confirm these findings.