Thoracofemoral Bypass Outcomes in the Vascular Quality Initiative.

OBJECTIVE: Thoracofemoral bypass (TFB) is used infrequently but is an alternative for selective patients with aortoiliac occlusive disease. There is limited data in the existing literature regarding TFB, with all studies being small, single-center series. We aim to describe perioperative and long-term survival, patency, and rate of major perioperative complications following TFB in a large national registry.

METHODS: The Vascular Quality Initiative (VQI) suprainguinal bypass module was used to identify patients undergoing TFB for occlusive disease from 2009-2019. A descriptive analysis was performed to provide rates of survival, patency, major complications, and freedom from major amputation in the perioperative period and at 1-year follow up. Major complications were compared by procedure indication with categorical variables analyzed using chi-square tests while continuous variables were analyzed using ANOVA. Kaplan Meier curve analysis was used to estimate survival at 1 and 5-year follow up intervals as well as freedom from major amputation at 1 year.

RESULTS: There were 154 TFB procedures identified. Fifty-nine patients (38.3%) had prior inflow bypass while 22 patients (14.2%) had prior leg bypass. Procedure indications included claudication (42.9%, n=66), rest pain (38.3%, n=59), tissue loss (12.3%, n=19), and acute limb ischemia (6.5%, n=10). Major complication (wound infection, respiratory, major stroke, new dialysis, cardiac, embolic, major amputation, occlusion) occurred in 31.2% of the cohort, and when examined by indication, acute limb ischemia and claudication cohorts had increased rate of major complication (acute limb ischemia: 60.0%, claudication: 34.8%, critical limb ischemia: 24.4%; p=.05). Survival at 30 days was 95.5% with Kaplan Meier estimated 1-year survival of 92.7% ± 2.2%. Primary patency at discharge from the index hospitalization was 92.9% and 89.0% at 1 year. Postoperative major amputation occurred in 1 patient during index hospitalization with Kaplan Meier estimated freedom from major amputation at 1-year follow up of 97.1% ± 2.2%. Two patients developed in-hospital bypass occlusion and 3 additional patients had occlusion occurring within 1 year for an overall freedom from occlusion rate of 96.8% at 1 year.

CONCLUSION: Thoracofemoral bypass is associated with a high rate of perioperative major complications; however, long-term survival and patency following the procedure remain acceptable when performed for limb salvage. High perioperative complication rates of TFB procedures performed for claudication suggest this procedure should be used rarely in this population. These data can be used to counsel patients and aid in decision making prior to operative intervention.