Role of simple and complex hybrid revascularization procedures for symptomatic lower extremity occlusive disease.
OBJECTIVE
Hybrid reconstructions have been increasingly used for multilevel revascularization procedures as surgeons have embraced endovascular interventions. The goal of this study is to define the role of simple and complex hybrid techniques in patients who need multilevel revascularization.


METHODS
All patients undergoing arterial revascularization (endovascular [EV], open, hybrid) between June 2001 and May 2008 were included. Hybrid procedures were stratified as simple (sHYBRID group) when the endovascular-treated segment was TransAtlantic Society Consensus II (TASC) A/B, and complex (cHYBRID group), when TASC C/D.


RESULTS
Of the 654 patients, 770 limbs (67% critical limb ischemia), 226 (29%) had open, 436 (57%) had endovascular, and 108 (14%) had hybrid procedures (56 sHYBRID, 52 cHYBRID). The HYBRID group was more likely to have hypertension, chronic obstructive pulmonary disease, American Society of Anesthesia (ASA) 4, and aortoiliac reconstructions, with more ASA 4 in the cHYBRID than the sHYBRID group. Length of stay in the HYBRID group was significantly longer than the EV group, but less than open-treated groups. Endovascular intervention was performed for inflow in 85%, for runoff in 5%, and for both inflow and runoff in the remaining 10% of hybrid cases. Eleven (20%) sHYBRID cases were staged, while all cHYBRID cases were performed simultaneously. Femoral endarterectomy was more frequent in cHYBRID (75% vs 23% in sHYBRID), infrainguinal bypass (17% vs 55%) was more common in sHYBRID, the remainder being femoro-femoral bypasses (8% vs 21%). Endovascular procedures were primarily iliac interventions (91% in sHYBRID, 88% in cHYBRID). Thirty-day myocardial infarction/death rate was significantly higher in the HYBRID than the EV group, with no difference within the HYBRID group. The patency rates were similar in the sHYBRID and cHYBRID groups, and comparable to the endovascular and open treated patients with similar disease complexity. Limb salvage in patients who presented with critical limb ischemia was better in the cHYBRID group than other groups. Overall survival was similar in all groups.


CONCLUSIONS
Complex and simple hybrid procedures enable multilevel revascularizations in high-risk patients with comparable patency and limb salvage. Femoral endarterectomy plays a central role, especially in complex hybrid repairs. An increase in perioperative morbidity and mortality was observed in the hybrid group, likely due to attempting revascularization in higher risk patients.
Dosluoglu
Hasan H
HH
Division of Vascular Surgery, VA Western NY Healthcare System, Buffalo, NY 14215, USA. dosluoglu@yahoo.com
Lall
Purandath
P
Cherr
Gregory S
GS
Harris
Linda M
LM
Dryjski
Maciej L
ML
D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000295:instrumentation; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D016009:Chi-Square Distribution; D015897:Comorbidity; D016638:Critical Illness; D019992:Databases as Topic; D004691:Endarterectomy; D005260:Female; D005263:Femoral Artery / Q000601:surgery; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality