Ann Vasc Surg. 2024 Apr 6:S0890-5096(24)00173-0. doi: 10.1016/j.avsg.2024.02.007. Online ahead of print.
ABSTRACT
BACKGROUND: We investigated the long-term safety and efficacy of anatomical and extra-anatomical bypass for the treatment of unilateral iliac artery disease.
METHODS: A systematic search on PubMed, Scopus and Web of science for articles published by June 2023 was performed. We implemented a two-stage individual participant data (IPD) meta-analysis and pooled survival probabilities using the multivariate methodology of DerSimonian and Laird. The primary endpoint was primary patency at five and ten years of follow-up.
RESULTS: Ten studies encompassing 1907 patients were included. The five- and ten-year pooled primary patency for anatomical bypass was 83.27% (95% CI:69.99- 99.07) and 77.30% (95% CI:60.32- 99.04), with a mean primary patency time representing the duration individuals remained event-free of 10.08 years (95% CI:8.05-10.97). The five- and ten-year pooled primary patency for extra-anatomical bypass was 77.02% (95% CI:66.79-88.80) and 68.54% (95% CI:53.32-88.09) with a mean primary patency time of 9.25 years, (95% CI:7.21-9.68). Upon two-stage IPD meta-analysis anatomical bypass displayed a decreased risk for loss of primary patency compared to extra-anatomical bypass, hazard ratio (HR) 0.51 (95% CI:0.30-0.85). The five- and ten-year secondary patency for anatomical bypass was 96.83% (95% CI:90.28-100) and 96.13% (95% CI:88.72.3-100). The five- and ten-year secondary patency for extra-anatomical bypass was 91.39% (95% CI:84.32-99.04) and 85.05% (95% CI:74.43-97.18), with non-statistically significant difference between the two groups. The five- and ten-year survival for patients undergoing anatomical bypass was 67.99% (95% CI:53.84-85.85) and 41.09% (95% CI:25.36-66.57). The five- and ten-year survival for extra-anatomical bypass was 70.67% (95% CI:56.76-87.98) and 34.85% (95% CI:19.76-61.44). The mean survival time was 6.92 years (95% CI:5.56-7.89) for the anatomical and 6.78 years (95% CI:5.31-7.63) for the extra-anatomical groups. The pooled overall thirty-day mortality was 2.32% (95% CI:1.12-3.87) with meta-regression analysis displaying a negative association between year of publication and mortality (β =-0.0065, p<0.01). Further analysis displayed a thirty-day mortality of 1.29% (95% CI:0.56-2.26) versus 4.02% (95% CI:1.78-7.03), (p=0.02) for studies published after and before the year 2000. Non-statistically significant differences were identified between the two groups concerning long-term and thirty-day mortality outcomes.
CONCLUSION: While we have demonstrated favorable long-term primary and secondary patency outcomes for both surgical techniques, anatomical bypass exhibited a reduced risk of primary patency loss potentially reflecting its inherent capacity to circumvent the anticipated disease progression in the distal aorta and the contralateral donor artery. The reduction in perioperative mortality observed in our review, coupled with the anachronistic demographic characteristics and inclusion criteria presented in the existing literature, underscores the imperative necessity for contemporary research.
PMID:38588957 | DOI:10.1016/j.avsg.2024.02.007
