Endobypass associated to ultradistal venous bypass for multilevel diseases in CLI patients

AIM: Treatment of critical limb ischemia (CLI) due to superficial femoral artery (SFA) and below-the-knee (BTK) vessels’ involvement could be compromised by the lack of a great saphenous vein (GSV) suitable in its entire length. The purpose of this study was to assess the efficacy of a hybrid endovascular and open lower limbs arterial reconstruction in these patients with multilevel CLI. METHODS: From 2005 to 2013, we performed hybrid endovascular and surgical treatment for limb salvage in SFA-BTK CLI. This consisted of percutaneous transluminal angioplasty (PTA) with or without stenting of the SFA, along with distal origin vein graft bypass. Inclusion criteria were: Rutherford category 5 or 6, lack of a suitable GSV; patency of the popliteal artery; focal, single lesion of the SFA (<5 cm in length); lesions of the three crural vessels >5 cm in length each. Follow-up was performed with duplex scan surveillance of both the bypass graft and PTA sites. RESULTS: The hybrid treatment could be performed in 23 patients. Almost all the SFA stenosis were treated with simple PTA (N.=15), except for the application of a bare metal stent in one patient, while in all the SFA occlusions PTA was completed with covered stents (N.=7). Twenty-three popliteal-to-distal vein bypass grafts have been performed. There were no perioperative PTA or bypass graft failures. Clinical improvement was achieved in 19 (82.6%) patients. Overall, primary and secondary patency, limb salvage, and survival rates were 75%, 95%, 88%, and 72% at 5 yrs, respectively. CONCLUSION: A hybrid strategy in multilevel SFA-BTK severe CLI is safe, effective, and durable. Additional studies are needed to validate these results.