Hybrid Endarterectomy and Endovascular Therapy in Multilevel Lower Extremity Arterial Disease Involving the Femoral Artery Bifurcation

Abstract

The objective of this study was to evaluate the feasibility and efficacy of hybrid therapy (combined endarterectomy-endovascular) in patients with complex peripheral multifocal steno-obstructive vascular disease involving the femoral artery bifurcation. Forty-one combined procedures were performed on 40 patients. Although the common femoral artery was usually treated with endarterectomy, endoluminal procedures were performed proximally in 12 patients (group 1), distally in 18 patients (group 2), and both upward and downward in 11 patients (group 3). Patients underwent clinical assessment and anklebrachial index measurement thereafter. Primary, assisted-primary, and secondary patency rates at 24 months were 59%, 66%, and 72%, respectively. Primary patency rates were lower in group 3 compared with groups 1 and 2 (P = 0.015). The limb salvage rate was 86.4% at the end of the follow-up period. Hybrid procedures provide feasible and effective treatment management of selected patients with multilevel lower extremity arterial disease involving the femoral artery bifurcation.Key words: Endarterectomy -Interventional radiography -Arteriosclerosis obliteransFemoral artery T he indications for the endovascular treatment of peripheral arterial disease have rapidly increased since the introduction of percutaneous transluminal angioplasty (PTA) and stenting. 1,2 The advantages of the endovascular approach include lower periprocedural morbidity and mortality. Short-term data from Bypass versus Angioplasty trials in Severe Ischemia of the Leg (BASIL) have confirmed this, with similar clinical outcome for the surgical and endovascular approach. Considerable progress has also been made in the endovascular treatment of infrapopliteal arterial occlusion. One study has demonstrated that infrapopliteal angioplasty is a reasonable primary treatment for critical limb ischemia patients with TransAtlantic InterSociety Consensus (TASC) A, B, or C lesions. 4 Due to the multilevel nature of peripheral arterial disease, iliac or femoral lesions accompanied by the femoral artery bifurcation (FB) disease are frequently observed. 5,6 Endovascular surgery is poorly suited to treating lesions in the FB because they are bulky and eccentric. In addition, the location of the lesions makes ipsilateral access difficult and stent placement impossible. As with the common femoral artery, the deep femoral artery is not generally favorable for endovascular surgery because it usually has either an orifice lesion involving the FB or a diffuse lesion along the length of the artery, which is often into its secondary and tertiary branches.Simultaneous hybrid endovascular and open lower extremity arterial reconstructive procedures have the advantage of eliminating the need for major surgery and avoiding separate staged interventions and their associated morbidity. Recently, several investigators have published results on several types of combined treatments for various patterns of iliac, femoral, and infrapopliteal diseases with promising outcomes.7-14 Mos...

Hybrid femoropopliteal procedures are associated with improved perioperative outcomes compared with bypass

“…17,[22][23][24] Some compare hybrid procedures on the basis of indications such as claudication, CLI, and acute limb ischemia or the direction of the endovascular intervention (inflow vs outflow). 13,18,19 Dosluoglu et al 20 compared hybrid revascularization with open and endovascular therapy. Like our findings, hybrid surgery was associated with decreased hospital length of stay and wound infection compared with open surgery.…”

“…[10][11][12] Lesions in this anatomic region are usually eccentric, are diffuse, and commonly involve a bifurcation, and because of rigid arterial wall and hip movement, there is an increased risk of stent fracture. [13][14][15] Treatment of disease in the CFA is crucial for FP revascularization. As such, CFA endarterectomy with patch angioplasty remains the standard treatment and is combined with FP bypass when indicated.…”

Hybrid Procedure Utilizing Stent Grafts to Stabilize Distal Flaps after Common and Superficial Femoral Endarterectomy

“…Furthermore, placing a stent across a joint or the inguinal ligament predisposes it to fracture and intimal hyperplasia [13] [14] [18]. The recent evolution of hybrid procedures, utilizing open and endovascular techniques, obviates the risks associated with CFA stenting and has gained increasing popularity in treating multifocal disease [15]- [24]. One advantage of the hybrid procedure is the ability to treat more complex anatomy using less invasive procedures in patients considered high medical risk [16].…”

“…Recently, hybrid techniques for multifocal atherosclerotic disease have gained popularity [15]- [24]. These procedures use the proven durability of common femoral endarterectomy with concomitant endovascular management for both inflow and outflow lesions.…”

Surgical Treatment of Atherosclerotic Lesion of Iliac Arteries by Method of Loop Endarterectomy

“…Сердечно-сосудистые заболевания / Cardiovascular medicine В настоящее время во всем мире для лечения ате-росклеротических поражений подвздошных арте-рий все шире применяются эндоваскулярные вме-шательства, включающие баллонную дилятацию и стентирование [1,2,3,4,5,6,7,8,9,10,11,12]. Однако наряду с ними существует другой малотравматич-ный способ лечения, приобретающий все большую популярность -эндартерэктомия при помощи раз-личных петель и колец (ПЭАЭ).…”