Hybrid approach tackles critical limb ischemia

Key clinical point: Hybrid-based iliofemoral endarterectomy provides robust inflow restoration comparable to aortofemoral bypass, with minimal perioperative morbidity.

Major finding: Primary patency was 100% with a mean follow-up of 13 months.

Data source: Five-year retrospective study in 40 limbs in 33 patients with critical limb ischemia.

Disclosures: The authors reported having no financial disclosures.

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The value of the hybrid approach

The combination of open surgical procedures with endovascular interventions has enriched the spectrum of vascular reconstructions significantly. These so-called hybrid procedures are especially worthwhile if pros and cons of both approaches could be combined and the groin could be considered as the hub. Technically spoken, the groin is the ideal hub for these kind of procedures. Why is that the case? Usually the surgical access to the common femoral artery (CFA) is easy. Furthermore the long-term results of femoral/retrograde iliac endarterectomy (often in combination with profundoplasty) are undoubtedly excellent. For the endovascular world, the (almost) NO-GO for any metal in the groin is still valid, and balloon dilatation of the femoral arteries is hemodynamically insufficient in most cases. However, PTA [percutaneous transluminal angioplasty] and stenting of the iliac arteries comes with good long-term results and avoids the sometimes-extended surgical access via the abdomen or the retroperitoneum.

Technically, it is advisable to perform the procedure in the following way: exposure of the CFA up to the inguinal ligament and down to the proximal superficial and deep femoral artery; puncture of the CFA in a noncalcified area and retrograde guide-wire access to the distal aorta (confirmation by angiography); balloon blockage of the proximal iliac artery (if technically possible; open endarterectomy of the CFA (including the proximal superficial and deep femoral artery; and retrograde ring-stripper endarterectomy of the iliac arteries and reconstruction of the femoral arteries (patchplasty, femoral transposition, profundoplasty). Balloon dilatation and stenting will be performed at the end of the procedure via a 7F or 9F sheath. We prefer balloon-expandable stents for the common and self-expandable stents for the external iliac artery, respectively. The contralateral groin should also be prepared for kissing stenting of both iliac arteries. Very rarely, an antegrade iliac access (via contralateral or brachial) access) is necessary. Whether or not covered stents have better long-term results is an open issue, however, covered stents should always be available to treat rare complications like an iatrogenic iliac rupture.

Especially Rutherford stage 5 or 6 patients very often present with multisegment disease including the femoropopliteal and the crural arteries. Since an even perfect inguinal inflow might not be sufficient in CLI [critical limb ischemia], these patients often need additional open or endovascular procedures. Again, the latter can be performed simultaneously via the hub femoral artery.

Even though hybrid procedures have been an essential part of vascular surgical practice for some years now, the Midwestern Vascular Surgical Society and Dr. Kavanagh have to be congratulated for raising this clinically very important topic again.

Dr. Hans-Henning Eckstein is a Professor at the Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, and is an associate medical editor for Vascular Specialist.




CHICAGO – A hybrid approach combining external iliac endarterectomy with stenting may offer vascular surgeons a more robust option to stenting alone or aortofemoral bypass in patients with critical limb ischemia.

“Hybrid-based iliofemoral endarterectomy provides a minimally invasive option for revascularization, producing robust inflow restoration and low perioperative morbidity,” study author Dr. Crystal Kavanagh of St. Joseph Mercy Health Center in Ann Arbor, Mich., said.

Dr. Crystal Kavanagh Patrice Wendling/Frontline Medical News

Dr. Crystal Kavanagh

The 5-year retrospective series, presented here at the annual meeting of the Midwestern Vascular Surgical Society, earned the prestigious Szilagyi Award for best clinical research.

Dr. Kavanagh and her colleagues crafted the hybrid technique because conventional open approaches in managing external iliac occlusive disease are associated with considerable morbidity. At the same time, long or multisegmental external iliac-to-femoral arterial lesions treated with stenting alone have produced poor patency and typically require additional outflow procedures, she explained.

The technique uses external iliac endarterectomy, aided with a traditional moll-ring stripper. A longitudinal, femoral cut-down is completed. A wire is advanced through the ipsilateral external iliac artery into the aorta after heparinization and obtaining access via an 18-gauge micropuncture in the common femoral artery. Intraluminal positioning is confirmed and a moll-ring endarterectomy is completed over the wire using a balloon to create the distal transection point, Dr. Kavanagh explained. The moll-ring is sized to the maximum diameter that will be accommodated by the ring.

After partially deflating the balloon, the plaque is extracted. A long-segment endarterectomy is typically completed, leaving a widely patent external iliac artery, she said.

In cases where adjunct iliac stenting is required, such as a proximal dissection flap, the stent size is larger than what is typically placed with stenting alone, Dr. Kavanagh observed.

The 2007 TASC (TransAtlantic InterSociety Consensus) recommendations suggest that TASC A lesions should undergo endovascular treatment as first-line therapy, while TASC D lesions should undergo traditional open surgical bypass.

Consensus has been slow to form for TASC B and C lesions, although most TASC B lesions undergo endovascular treatment and most TASC C lesions undergo open bypass.

Among the 40 limbs in the series, a common iliac (CI) artery stent (mean diameter, 8 mm: mean length, 59 mm) was placed in 19 limbs; a CI-to-external iliac (EI) stent (mean diameter, 10 mm; mean length, 100 mm) in 7 limbs; and an EI stent (mean diameter, 10 mm; mean length, 100 mm) in 21 limbs.

None of the iliac lesions were TASC category A or B, 17% were TASC C, and 83% TASC D. Concomitant infrainguinal disease of these patients had femoral/popliteal lesions, of which 16% were type A, 33% type B, 19% type C, and 32% type D.

Half of the 33 patients had three-vessel runoff, 33% two-vessel runoff, and 17% single-vessel runoff.

The hybrid procedure was completed as planned in all 40 limbs, Dr. Kavanagh said. There was no intraoperative or 90-day mortality.

Perioperative complications were minimal, with a 30-day readmission rate of only 12%, she said. This included one patient with one-vessel run-off who re-presented with ischemia requiring common femoral-to-below-the-knee popliteal bypass.

A second patient was admitted at postoperative day 47 with an infected pseudoaneurysm requiring patch angioplasty revision, for a 90-day readmission rate of 15%.

“Concerns about potential plaque rupture or hemorrhage can easily be dealt with via a covered stent graft, given intraluminal wire access throughout the procedure,” senior author Dr. Abdulhameed Aziz said in an interview.

Significant gains were made from baseline in postoperative ankle-brachial index (mean, 0.4 vs. 076; P less than .001), as well as in toe pressures (mean, 32 mm Hg vs. 60 mm Hg; P less than .001), Dr. Kavanagh said.

After a median follow-up of 13 months, primary patency was 100%.

“Combined common femoral endarterectomy with iliac stenting has demonstrated comparable patency to operative bypass in the short term,” she said.

“We theorize that the longer-segment endarterectomy, in our case essentially going from the iliac bifurcation to the common femoral, may produce a more durable result ... Stenting the proximal transection point may prevent restenosis.”

The authors reported no financial disclosures.

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