Aortic reconstruction vs extra-anatomic bypass and angioplasty. Thoughts on evolving a protocol for selection.

One hundred forty-eight patients were evaluated for inflow revascularization and stratified by age, vascular anatomy, medical history, and cardiac functional class into aortic reconstruction (AR), extra-anatomic bypass (EAB), or iliac angioplasty based on a protocol that restricted AR to good-risk patients and liberalized indications for EAB. Fifty-five patients underwent AR with a 1.8% mortality, 1.8% myocardial infarction and 12% morbidity, and cumulative life-table patency of 94% at two years; 69 patients underwent EAB with no mortality and negligible morbidity; cumulative life-table patency was 93% at two years for crossover femoral and 83% at two years for axillofemoral grafts. Operative selection based on a protocol restricting AR to better-risk patients and liberalizing use of EAB may decrease overall patient mortality and morbidity without jeopardizing limb preservation.