The Role of Hybrid Femoropopliteal Revascularization in High-risk (ASA 3-4) Patients: A Decade of Dual Center Clinical Experience

The Role of Hybrid Femoropopliteal Revascularization in High-risk (ASA 3-4) Patients: A Decade of Dual Center Clinical Experience

Background: The present chapter focuses on the potential clinical advantage of hybrid revascularization in patients with serious infrainguinal multilevel occlusive disease undergoing typical femoral artery (CFA) endarterectomy coupled with femoropopliteal endovascular recanalization in high-risk ASA class 3-4 patients.

Materials and Methods: A series of 205 hybrid infrainguinal procedures conducted in 178 ASA Class 3-4 patients (Rutherford group 2-6 ischaemic presentations) were retrospectively analysed from January 2009 to November 2019. During a mean follow-up period of 44.9 months, patient demographics, unique risk factors, technological features, parallel to patency, limb salvage and survival outcomes were analyzed. In 198 (96 percent) of all ischaemic limbs, long (>15 cm) and intermediate (5-15 cm) CTOs were present at the same time as extreme CFA atherosclerotic disease. In 172 (84 percent) cases, two or three runoff tibial trunks were evinced, while in 78 (38 percent) cases, moderate to extreme arterial calcifications were present.

Results: As the surgical approach was successful in all cases, in 190 (93 per cent) cases, the endovascular phase of all hybrid approaches was technically rewarding. In 75 percent of cases, postoperative ABI improved (> 1.5), while clinical presentations in 182 (89 percent) limbs received at least one Rutherford grade. In this particular ‘high-risk’ category of patients, the postoperative 30-day mortality rate noted was 3.3%. The median stay in the hospital was 6.2 days (3-14 days). Primary estimates of patency indicated 88 percent (95 percent CI 84 percent to 91 percent) and 66 percent (95 percent CI 56 percent to 75 percent) at 12 and 60 months, while limb salvage at the same time intervals was 93 percent (95 percent CI 88 percent to 95 percent) and 80 percent (95 percent CI 72 percent to 86 percent). Together with CTOs duration (>15 cm / p=0.016), extreme calcifications (p=0.049), poor tibial runoff (p=0.018 and p=0.001 for 1, and 0 permeable trunks), GLASS/FP grade ‘4’ lesions (p=0.039) and stent length (>6 cm / p=0.001), global risk factors such as smoking (p=0.003) and female gender (p=0.001) showed parallel negative influence on primary patency.

Conclusion: In high-risk ASA 3-4 patients, hybrid infra-inguinal revascularization can provide a beneficial alternative for treatment options. For achieving adequate arterial reconstruction and limb salvage result, careful patient selection and technique preparation seem important.

Author (s) Details

Vlad-Adrian Alexandrescu,
Department of Vascular Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium.

Dr. Thibault Barriat
Department of Anesthesiology, Princess Paola Hospital, Marche-en-Famenne, Belgium.

Dr. Sophie Schoenen
Department of Vascular Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium.

Dr. Elisa Antonelli
Department of Vascular Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium.

Mircea Popitiu,
Department of Vascular Surgery and Reconstructive Microsurgery, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.

Dr. Inès Zekhnini
Department of Vascular Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium.

View Book :-  https://stm.bookpi.org/RTCMS-V8/issue/view/3

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