Unilateral Lower Extremity Inflow Procedures: Is There a Preferred Operation?

Abstract

There is no consensus on optimal surgical treatment of unilateral aortoiliac occlusive disease. The purpose of this study was to compare indications for and results of the various options. Patients undergoing primary, unilateral inflow procedures without adjunctive infrainguinal bypass over a 10-year period were analyzed. Groups were defined as Ax F for unilateral axillofemoral bypass (18); IF for aortounifemoral (two) or ipsilateral iliofemoral (29) bypass; and CF for contralateral iliac-to-femoral (six) or femorofemoral (10) bypass. Risk factors, level and severity of occlusive disease, morbidity, mortality, cumulative primary patency, and limb salvage were compared. Median age was 72 years, limb salvage was the surgical indication in 61% of patients. Infrainguinal occlusion was present in 76.6% of the whole group, while 27.7% had prior outflow procedures. Compared with the other groups, AxF patients were older with more comorbidity and had more contralateral iliofemoral occlusive disease (88.9% vs 48.4%, p < 0.01). IF patients more frequently had prior outflow operations (48.4% vs 11.1%, p < 0.01). Comorbidity and presence of contralateral iliac disease most strongly influenced operation choice. Overall, hospital mortality rate was 3.1% and morbidity rate was 21.5%, not significantly different between groups. Early occlusion occurred in three patients, two IF and one AxF. Life-table primary patency rate was 87.8% (SE ± 4.9%) at 2 years and was not significantly different among the groups. Three patients ultimately required contralateral inflow procedures, 2 AXF, 1 IF (p = NS). Unilateral inflow operations achieve reasonable patency and good limb salvage rates. Shorter length reconstructions were utilized preferentially when contralateral disease was not severe, but despite greater age, comorbidity, and occlusive disease, axillounifemoral bypass results were not inferior to more direct reconstructions.