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In the continuously evolving efforts to provide optimum revascularization for high risk Critical Limb Ischemia patients, vascular surgeons around the world have widely adopted hybrid approach. This combination of the advantages of open and endovascular techniques allows the implementation of tailored complex multi-level reconstruction plans usually within a single setting [1-3].
What started over 40 years ago, with the combination of simple iliac angioplasty and femoro-femoral bypass  is gradually increasing in complexity & becoming a widely accepted therapeutic option. Furthermore, the increasing sophistication of minimally invasive endovascular techniques with successful treatment of multi-segmental lesions has contributed to a reduced morbidity & duration of hospital stay when Hybrid revascularizations are performed . The final benefit thus is full revascularization of the target arterial bed with an acceptable risk.
Gaps & Inconsistencies in literature on hybrid procedures stem partially from the variable clinical presentations, timing of hybrid reconstruction (single setting vs. stages) and the wide range of open surgical & endovascular approaches adopted. In addition to the above, definitions & terminology vary between centers making comparison very difficult [1,2,6]. Further research into the area is definitely needed, however the available literature suggests promising outcomes, comparable in efficacy to the current standards of care. This is increasingly important as a significant proportion of patients require multiple revascularizations to prolong amputation free survival and hence require ever evolving creative solutions [5,7].
At the center of these procedures is the dissection of the femoral artery and its bifurcation. Hence, depending on thecase open endarterectomy & patch angioplasty is performed, or it is employed as the inflow for a femoro-distal reconstruction. It is quite likely that in the next few years technological advancement may result in single endovascular solutions. But as the current literature stands though, the results of Common Femoral Artery open endarterectomy with autogenous angioplasty are superior in terms of durability to available endovascular options.  Femoro-Popliteal or Femoro-Distal bypasses are used either as an alternative to long segment SFA CTO Endovascular treatment or as a last resort following in-stent occlusions. Tibial and Pedal angioplasty might be required concomitantly in more complex cases to improve the distal run off & prevent early thrombosis, & has shown good results [9,10].
Higher incidence of post-operative bleeding can be expected due to continuous anti platelets and the higher doses of heparin used during and after the procedures. It is advisable to avoid the use of prosthetic materials whenever possible due to their association with an increased risk of post-operative wound infections. In part this is due to the vascular risk factors and other patient co-morbidities which result in immuno-compromise and delayed wound healing, in addition to the high incidence of existing infection within the patient’s ulcer or gangrenous lesion.
A 64 years old male teacher, known case of accelerated atherosclerosis and uncontrolled diabetes mellitus, hypertension, Ischemic heart disease (post CABG). The patient was also suffering from peripheral arterial disease manifesting as short-distance left lower limb claudication for which he underwent multiple endovascular interventions by an invasive cardiologist over the last two years. Consequently, the patientended up with a total of 7 implanted along the entire course of his Left SFA.
He presented to our A/E department complaining from
severe left foot rest pain resistant to analgesia. On examination,
the patient had a +1 femoral pulse with absent popliteal &
distal pulses. The foot was cold with absent dorsalis pedis
Doppler signals, monophasic posterior tibial signals and an
Following routine laboratory investigations, optimization
& nephro-protective agents the patient was taken to the
operating theatre. Initial access was done with a 6Fr
sheath inserted retrogradely into the right CFA. Diagnostic
angiography revealed significant stenosis with heavy
calcification at the ostiun of bilateral iliac arteries, complete instent
occlusion of the Left SFA and a single vessel run off with
multiple stenotic segments within the posterior tibial artery
& complete occlusion of anterior tibial & peroneal arteries.
Dissection of the Left Femoral Bifurcation, distal Popliteal
Artery and Ipsilateral GSV harvesting were performed prior
to the administration of heparin. Hence an 8000 IU Bolus of
unfractionated heparin was given intravenously and a 6Fr
sheath was inserted retrogradely into the left common femoral
artery (Figure 1).
Recanalization of the inflow and deployment of kissing 9mm
balloon expandable stents was done at the ostia of the Common
Iliac arteries with restoration of a good inflow. Autovenous
reverse Femoro-Popliteal bypass was performed in standard
fashion. 4Fr sheath was then inserted into the distal segment of
the bypass in antegrade fassion. Angioplasty of tibioperoneal
trunk and posterior tibial artery with reconstruction of pedal
arch was performed as the final component of the treatment to
improve outflow and prevent early thrombosis of the bypass.The procedure was done in epidural anesthesia with minimal
sedation and the patient remained hemodynamically stable
throughout the surgery.
His post-operative course was uneventful with resolution
of rest pain, mobilization on the 2nd post operative day & was
discharged walking on the 7th post operative day. The patient
continues to follow up in the outpatient clinic & does not
currently complain of intermittent claudication or rest pain.
Multilevel atherosclerotic arterial disease affecting the
lower extremities requires complex treatment strategies
involving inflow and outflow arterial reconstructions to
prolong amputation free-survival & allow healing of defects.
Multi-segmental arterial disease is frequently associated
with significant co-morbidities and patients presenting
with critical Limb Ischemia are typically high risk for major
operative procedures. Hybrid procedures combining benefits
of open reconstructions and endovascular techniques enable
multilevel revascularizations in high-risk CLI patients with
favorable patency and limb salvage and currently comprise
15% of all revascularizations done at our center, with
increasing popularity worldwide. Dissection of femoral artery
plays a central role. For selected groups of patient is Hybrid
approach not only the best solution but the only one possible.