Could the Endo-first Strategy Really Be Better? Could the Endo-first Strategy Really Be Better?

Lee JT. — Sat, 01 Sep 2012 00:00:00 GMT

Despite all the hoopla surrounding minimally invasive techniques that have defined the past decade of the endovascular revolution in vascular surgery, some sobering realizations have emerged. Although most vascular specialists have embraced endovascular aortic aneurysm repair, critics bemoan the loss of open aortic skill and point to durability issues as endo-enthusiasts push the boundaries. Carotid stenting vs endarterectomy continues to be a hotly debated topic for treatment, credentialing, and reimbursement. Endovascular infrainguinal interventions are still quite popular despite growing evidence that aggressive endo-first misadventures lead to worse outcomes for open leg bypass. Against this backdrop, Danczyk and colleagues from Oregon Health & Science University and Portland Veterans Affairs Medical Center present us with an important article regarding open reconstruction after failed endovascular attempts at treating aortoiliac occlusive disease (AIOD).

Outcomes of Open Operation for Aortoiliac Occlusive Disease After Failed Endovascular Therapy Open Operation for AIOD After Failed ET

Danczyk RC, Mitchell EL, Petersen BD, et al. — Sat, 01 Sep 2012 00:00:00 GMT

Objectives

To compare patient outcomes of primary open operation for aortoiliac occlusive disease (AIOD) with those of secondary open operations for failed endovascular therapy (ET) of AIOD.

Design

A retrospective cohort study was performed analyzing demographic characteristics, comorbidities, and outcomes.

Setting

Affiliated Veterans Affairs Hospital from January 1, 1998, through March 31, 2010.

Patients

Patients who underwent primary open operation for AIOD or secondary open operation for failed ET of AIOD.

Main Outcome Measures

Overall survival and limb salvage.

Results

Primary open operations (n = 153) were 67 aortobifemoral grafts (43.8%), 38 axillobifemoral grafts (24.8%), and 48 femoral-femoral grafts (31.4%). Secondary open operations (n = 35) were 28 aortobifemoral grafts (80.0%), 5 axillobifemoral grafts (14.3%), and 2 femoral-femoral grafts (5.7%). Mean (SD) 5-year survival was 48.2% (5.6%) and 66.8% (10.0%), respectively, for patients undergoing primary vs secondary open surgery for AIOD (P = .01). There were 7 amputations during a mean follow-up of 3 years, all in the primary open surgery group.

Conclusions

Despite a higher proportion of coronary artery disease and a 20% conversion of claudication to critical limb ischemia after failed ET for AIOD, survival was longer in patients undergoing secondary vs primary open surgery. Patients who underwent open surgery after failed ET for AIOD did not require amputation. Failed ET for AIOD does not lead to worse outcomes for patients undergoing open surgery for AIOD.

JAMA Surgery: Atherosclerosis Topic Collection

Could the Endo-first Strategy Really Be Better? Could the Endo-first Strategy Really Be Better?

Outcomes of Open Operation for Aortoiliac Occlusive Disease After Failed Endovascular Therapy Open Operation for AIOD After Failed ET