Simultaneous hybrid revascularization for symptomatic lower extremity arterial occlusive disease

Abstract

Multilevel revascularization, using a combination of endovascular and open (hybrid) surgery, is increasingly being used. Hybrid surgery allows complex anatomy to be treated by minimally invasive procedures in medically high risk patients. The aim of the present study was to report a novel hybrid surgery for lesions in the multilevel lower extremity arteries and to evaluate the clinical outcomes. Consecutive patients who presented at a single institution between March 2009 and Feburary 2012 were selected for inclusion in the study. The patients had disabling claudication or critical limb ischemia and underwent treatment for revascularization by open surgery or by a combination of open surgery and endovascular procedure. Retrospective analysis was conducted from a prospectively collected database. All procedures were performed by a vascular surgeon in an operating room. Postoperative surveillance in outpatient clinics was conducted at 3 and 6 months and every 6 months thereafter. A total of 76 patients were included in the study with a mean age of 67.1±11.3 years (range, 42-94 years) and the male to female ratio was 67:9. The most common indication for revascularization was Rutherford category IV (resting pain). The immediate technical success rate of hybrid surgery was 90.5%, with an overall limb salvage rate of 97.4%. The primary patency rates of the hybrid and open groups were 100 and 90.9%, respectively (P=0.441). Therefore, the results of the present study indicate that hybrid surgery is a feasible option for the treatment of multilevel peripheral arterial occlusive disease, showing favorable patency and limb salvage rates. These observations indicate that femoral endarterectomy plays a vital role in hybrid surgery.

Keywords: artery; endovascular procedures; hybrid; lower extremity; revascularization.

Figure 1

Combined femoral endarterectomy and bilateral iliac kissing stent. (A) Preoperative CTA showing a highly calcified lesion on the right CFA and bilateral common iliac arteries. (B) Image of the right CFA showing calcified plaques which were endarterectomized. (C) Postoperative CTA showing patent iliac stenting and a widely opened right common iliac artery. CTA, computed tomography-angiography; CFA, common femoral artery.

Figure 2

Iliac stenting and crossover femorofemoral bypass. (A) Preoperative CTA showing long segment occlusion of the right iliac artery and focal stenosis of the left common iliac arteries. (B) Image during hybrid surgery showing the artificial graft for a bypass and the vascular introducer sheath for endovascular procedure. CTA, computed tomography-angiography.

Figure 3

Distal origin bypass and iliac stenting. (A) Preoperative CTA showing long segment occlusion of the left tibio-peroneal artery and tight stenosis of the left common iliac artery. (B) Contrast angiogram of the placed iliac stent. (C) Image of the bypassed vein graft. (D) Postoperative CTA (maximal intensity projection image) of the patent bypassed graft and iliac stent. CTA, computed tomography-angiography.

Figure 4

Femoral endarterectomy and endovascular treatment of a lesion in the SFA. (A) Preoperative CTA showing tight stenosis on the left CFA and SFA. (B) Image of the inserted introducer sheath for endovascular treatment of a lesion in the SFA. CTA, computed tomography-angiography; SFA, superficical femoral artery; CFA, common femerol artery.

Figure 5

Primary patency rates in patients of the hybrid and open surgery groups. No statistically significant difference was observed between the groups.

Figure 6

Secondary patency rates in patients of the hybrid and open surgery groups. No statistically significant difference was observed between the groups.