A comparative cohort study of totally laparoscopic and open aortobifemoral bypass for the treatment of advanced atherosclerosis

Abstract

Syed SH Kazmi,1 Jørgen Junkichi Jørgensen,1,2 Jon Otto Sundhagen,1 Anne Helene Krog,1,2 Tor L Flørenes,1 Dagfinn Kollerøs,3 Michael Abdelnoor2,4,5 1Department of Vascular Surgery, Heart, Lung and Vascular Disease Clinic, Oslo University Hospital, 2Faculty of Medicine, Oslo University, 3Department of Anaesthesiology, Oslo University Hospital, 4Unit of Epidemiology and Biological Statistics, 5Centre for Clinical Heart Research, Faculty of Medicine, Oslo University, Oslo, Norway Background: Totally laparoscopic aortobifemoral bypass (LABF) procedure has been shown to be feasible for the treatment of advanced aortoiliac occlusive disease (AIOD). This study compares the LABF with the open aortobifemoral bypass (OABF) operation. Methods: In this prospective comparative cohort study, 50 consecutive patients with type D atherosclerotic lesions in the aortoiliac segment were treated with an LABF operation. The group was compared with 30 patients who were operated on with the OABF procedure for the same disease and time period. We had an explanatory strategy, and our research hypothesis was to compare the two surgical procedures based on a composite event (all-cause mortality, graft occlusion, and systemic morbidity). Stratification analysis was performed by using the Mantel–Haenszel method with the patient–time model. Cox multivariate regression method was used to adjust for confounding effect after considering the proportional hazard assumption. Cox proportional cause-specific hazard regression model was used for competing risk endpoint. Results: There was a higher frequency of comorbidity in the OABF group. A significant reduction of composite event, 82% (hazard ratio 0.18; 95% CI 0.08–0.42, P=0.0001) was found in the LABF group when compared with OABF group, during a median follow-up time period of 4.12 years (range from 1 day to 9.32 years). In addition, less operative bleeding and shorter length of hospital stay were observed in the LABF group when compared with the OABF group. All components of the composite event showed the same positive effect in favor of LABF procedure. Conclusion: LABF for the treatment of AIOD, Trans-Atlantic Inter-Society Consensus II type D lesions, seems to result in a less composite event when compared with the OABF procedure. To conclude, our results need to be replicated by a randomized clinical trial. Keywords: aortic surgery, laparoscopy, atherosclerosis, aortoiliac atherosclerosis, aortobifemoral bypass, competing risk analysis, minimally invasive surgery