title: The combination of surgical embolectomy and endovascular techniques may improve outcomes of patients with acute lower limb ischemia.
abstract: OBJECTIVE
  Surgical arterial thromboembolectomy (TE) is an efficient treatment for acute arterial thromboemboli of lower limbs, especially if a single large artery is involved. Unfortunately, residual thrombus, propagation of thrombi, chronic atherosclerotic disease, and vessel injuries secondary to balloon catheter passage may limit the clinical success rate. Intraoperative angiography can identify any arterial imperfection after TE, which may be corrected simultaneously by endovascular techniques (so-called "hybrid procedures," HP). The aim of this study is to compare outcomes of surgical TE vs HP in patients with acute lower limb ischemia (ALLI).
  
  
  METHODS
  From 2006 to 2012, 322 patients with ALLI were admitted to our department. Patients received urgent surgical treatment using only a Fogarty balloon catheter (TE group = 112) or in conjunction with endovascular completion (HP group = 210). In-hospital complications, 30-day mortality, primary and secondary patency, reintervention rate, limb salvage, and overall survival rates were calculated using the Kaplan-Meier method and compared by log-rank test.
  
  
  RESULTS
  HPs (n = 210) following surgical TE consisted of angioplasty (PTA) ± stenting in 90 cases, catheter-directed intra-arterial thrombolysis + PTA ± stenting in 24, thrombus fragmentation and aspiration by large guiding catheter + PTA ± stenting in 67, vacuum-based accelerated thromboaspiration by mechanical devices in 9, and primary covered stenting in 12. Estimated primary patency was 90.4% vs 70.4% at 2-year and 87.1% vs 66.3% at 5-year follow-up, respectively, for HP and TE patients (hazard ratio, 3.1; 95% confidence interval, 1.78-5.41; P < .01). A hazard ratio of 2.1 for limb salvage was noted for the HP group (95% confidence interval, 1.01-4.34; P = .03). Estimated freedom from reintervention at 1 year was 94.4% for HP vs 82.1% for TE patients, and 89% vs 73.7% at 5 years, respectively (P = .04).
  
  
  CONCLUSIONS
  HPs for ALLI may represent the tools that, when applied to specific clinical scenarios, hold the potential to reduce the morbidity previously associated with acute arterial occlusion.
authors.affiliation: Department of Medicine, Surgery, and Neuroscience, Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy. Electronic address: dedonato@unisi.it.
authors.forename: Gianmarco
authors.initials: G
authors.lastname: de Donato
authors.affiliation: Department of Medicine, Surgery, and Neuroscience, Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Setacci
authors.affiliation: Department of Medicine, Surgery, and Neuroscience, Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy.
authors.forename: Pasqualino
authors.initials: P
authors.lastname: Sirignano
authors.affiliation: Department of Medicine, Surgery, and Neuroscience, Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Galzerano
authors.affiliation: Department of Medicine, Surgery, and Neuroscience, Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy.
authors.forename: Rosaria
authors.initials: R
authors.lastname: Massaroni
authors.affiliation: Department of Medicine, Surgery, and Neuroscience, Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Setacci
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000295:instrumentation; D003131:Combined Modality Therapy; D017128:Embolectomy / Q000009:adverse effects / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D061185:Mechanical Thrombolysis; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013396:Suction; D015912:Thrombolytic Therapy; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency