OBJECTIVE: Aortobifemoral bypass (ABFB) is the gold-standard procedure for aortoiliac occlusive disease (AIOD). Axillobifemoral bypass (AxBFB) has been alternatively used for revascularization in patients who are deemed high risk for ABFB. However, in the endovascular era, covered endovascular reconstruction of aortic bifurcation (CERAB) is being used frequently in high- and standard-risk patients with AIOD. We aimed to compare the midterm outcomes of ABFB, AxBFB, and CERAB in the Vascular Quality Initiative (VQI) Medicare-linked database. METHODS: All patients with AIOD who underwent aortoiliac reconstruction by ABFB, AxBFB, or CERAB during 2013 to 2019 in the VQI Medicare-linked database were included. The primary outcome was amputation-free survival (AFS). The secondary outcomes were overall survival (OS), limb salvage (LS), and freedom from reintervention (FFR). Outcomes were assessed at 1 and 3 years. Kaplan-Meier estimates and Cox regression were used for the analyses. RESULTS: Three cohorts of patients undergoing ABFB (N = 1906
60.4%), AxBFB (N = 1077
34.1%), and CERAB (N = 173
5.5%) were studied. The patients in the AxBFB and CERAB cohorts were older than those in the ABFB cohort and were more likely to have comorbidities compared with their ABFB counterparts. Three-year AFS was 79.4%, 54.6%, and 71.1% in the ABFB, AxBFB, and CERAB cohorts, respectively (P <
.002). After adjusting for potential confounders, AxBFB was associated with higher hazards of major amputation/death compared with ABFB at 3 years (adjusted hazard ratio [aHR], 1.89
95% confidence interval [CI], 1.61-2.23
P <
.002) but CERAB was not (aHR, 1.27
95% CI, 0.84-1.91
P = .251). AxBFB was also associated with higher hazards of major amputation compared with ABFB at 3 years (aHR, 1.74
95% CI, 1.05-2.90
P = .032) but CERAB was not (aHR, 2.14
95% CI, 0.73-6.31
P = .166). On the other hand, CERAB was associated with increased hazards of 3-year reintervention (aHR, 1.75
95% CI, 1.16-2.64
P = .007) compared with ABFB. CERAB was also associated with lower hazards of major amputation/death at 1 year compared with AxBFB (aHR, 0.62
95% CI, 0.38-0.99
P = .048) but not at 3 years. CONCLUSIONS: We found that CERAB is comparable to ABFB in terms of OS, LS, and AFS, albeit with a substantial increase in reintervention rate at 3 years. AxBFB had worse OS, LS, and AFS compared with ABFB. CERAB was associated with higher AFS compared with AxBFB at 1 year. This national contemporary study supports the use of CERAB as a safe and durable alternative to ABFB and AxBFB. However, further prospective studies are necessary to confirm our findings.