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during endovascular treatment of thrombus without a significant difference in bleeding complications
combinedwithurokinaseorrt-PAadministration.
6,19
B.Thrombolysis
1. In1974, Dotteret al reported theinitial studyin 17patients ofefficacyof low-dose streptokinase
thrombolysisinacutethrombus,witha35%successrateofclotlysisbalancedbya24%rateonmajor
bleeding.20Hedescribedpositioningside-holecathetersintotheobstructiveclottoperfusestreptokinase
proximalor intothe lesion,using adose1/100thofthesystemictherapeuticdose in thefirst reportof
catheter-directed thrombolysis. Thrombolysis is commonly performed now, with decades of data
supporting its use as first-line therapy in acute limb ischemia in the absence of patient-based
contraindicationsaslongasexpectedtimetorestorationofflowtothejeopardizedlimbissufficientfor
limbsalvage.
2. Once arterial access is obtained, diagnostic angiography ofthe lower extremity vasculature canbe
performed to identify the level of the thrombotic occlusion not only to formulate the endovascular
approachbutalsoforsurgicalplanningifrevascularizationfails.The“guidewiretraversaltest”hasbeen
showntobeanimportantpredictoroftechnicalsuccessofthrombolysistherapy.19Cautiousmanipulation
of the guidewire to avoid vascular injury while crossing the thrombus is paramount. In the event the
guidewire cannot be advanced through the lesion entirely, the catheter may be positioned within the
proximal portion of the thrombus. Although many catheters exist on the market for thrombolysis,
essentiallyanymulti–side-holecatheterthatreachesthelesionmaybeusedforlyticdrugdeliverytothe
thrombus (Cragg-McNamara; ev3 Endovascular Inc, Plymouth, MN and Unifuse: AngioDynamics,
Latham,NY).
3.Techniquesforinfusingthrombolyticagentsintotheclotvarybasedonwherethecatheterisinitially
positioned(proximaltoclot,insideofclot,oratdistalend),whetherthecatheterismovedproximallyor
distallyduringthecourseofinfusion,andwhetherlyticdoseisconstant,graded,orperiodicallyforcedto
optimizedelivery of drug tothe lesion. Intrathrombus infusion involves passing the infusioncatheter
throughthe thrombus torelease lytic into thethrombus,which is most commonlyemployed and yields
improved clot dissolution. Intrathrombus lacing involves use of a catheter positioned within the clot
with gradual withdrawal as thrombolysis occurs to administer lytic throughout the lesion. These two
techniquesarefavoredbasedonthebalancebetweenmosteffectiveandleastdemanding.
21
4.Withthecatheterinplaceandsecured,thepatientcanbemonitoredinintensivecareunit(ICU)orstep
downtoassessforany signsofbleeding,hematologicabnormalityuntilrepeatangiogramisperformed
within12-24hoursofinitiationoflysis.Ifthereisresolutionofthrombus,anyunderlyingvascularlesion
thatpredisposedtothrombuscanbetreatedatthattime.
C.MechanismofActionandDosingofThrombolyticAgent
1. Thrombolytic agents are serineproteases thatwork by converting plasminogen to plasmin. Plasmin
acts to break the cross-links between fibrin molecules, which subsequently lyses the clot. Currently
available thrombolyticagentsfor lower extremity lysis are recombinant tissueplasminogen activators,
including alteplase (Genentech), reteplase (EKR therapeutics), and tenecteplase (Genentech).
Streptokinase,althoughitwasthefirstthrombolyticagentavailable,haslimitedclinicaluseintheUnited
States owingtoantigenicity,higherbleedingrates,andlesserefficacy.Urokinase,a directplasminogen
activator,isnolongeravailableintheUnitedStatesowingtomanufacturingissues.
2.Therearenodatatosupporttheroutinemonitoring oflaboratoryvaluesduringthrombolysis.Serum
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fibrinogenlevel is thought topredict bleeding, but this has not been validated. In the PURPOSE trial
(Prourokinasevsurokinaseforrecanalizationofperipheralocclusions,safety,andefficacy),Ourieletal.
found that 81% of patients withserum fibrinogen<100 mg/dL had a bleedingcomplication(major or
minor) compared with patients with fibrinogen>100 mg/dL who had a bleeding complicationrate of
59%.22 Another study of 36 patientsreceivingreteplase showed that there was significant fibrinogen
depletionandthat the percent decrease inlevel correlated to bleeding complications. Major bleeding
complicationswereassociatedwithamean72%decreaseinfibrinogenwhileminorcomplicationswere
associatedwitha46%decreaseinfibrinogen.
23
D.ContraindicationstoThrombolysis
Bleedingisamajorconcern with theuseofany fibrinolytictherapy. Thecontraindications to catheterdirectedthrombolysisoriginatefromexperiencewiththeuseofsystemicthrombolysis.Dataareavailable
whichshowincomparisonthatlessbleedingeventsoccurwithcatheter-directedthrombolysis,makingit
importanttoindividualizetherisk-benefitratioofendovascularinterventioninpatientspresentingwith
ALI.24 Absolute contraindications include ongoing bleeding, intracranial hemorrhage, compartment
syndrome,andseverelimbischemiathatrequiresimmediatesurgicalintervention.17Otherconsiderations
whichmayserveasrelativecontraindicationsincludethefollowing:withinthepast3months,ahistoryof
eyesurgery,neurosurgery,orintracranialtrauma;withinthepast2months,ahistoryofstrokeortransient
ischemic attack;within thepast 10 days, a history ofmajor surgery, major trauma, or gastrointestinal
bleeding;andlastly,ahistoryofanintracranialneoplasmorseverecontrastallergyshouldalsobetaken
intoaccount.
17
1.RandomizedControlledTrialsofCDT
Early randomized control data supporting the use of catheter-based thrombolysis comes from the
Rochestertrial,STILEStrial,andtheTOPAStrial,whicharereviewedbelow.Arecentmeta-analysisof
literature from 1990 to 2014 including these trials to compare open surgical versus endovascular
managementofALIshowsoverallthatlimbsalvageandamputationratesaresimilarandacceptableby
bothmodalitiesandareprobablycomplementaryinrestoringadequateflowtothethreatenedlimb.25In
theselectedpatient,datasupportcatheterdirectedthrombolysis(CDT)asfirst-linetherapyinRutherford
classI,IIa,andpossibly IIblimbischemia givensimilarityinearlyoutcomes toincludelimb salvage,
amputationfreesurvival,andsurvivaldespitepossibilityoffutureinterventions.
26
2.RochesterTrial
114patientswithsignsandsymptomsofALI<7dayswererandomizedtocatheter-directedthrombolysis
(urokinase)versussurgery.27Thrombolysisresultedinresolutionofthrombusin70%ofcases,withthe
remainder proceeding to surgery. At 30 days, the catheter-directed thrombolysis group had superior
amputation-free survival, but at one year limb salvage rates were similar between groups. Not
unexpectedly, the surgical group had more cardiopulmonary complications (49% vs 16% in the CDT
group),possiblydrivingtheearlysurvivalbenefitoftheendovascularstrategy.Medianlengthofhospital
stay was similar between groups (11 d), with slightly higher hospital cost in the thrombolysis group
($15,672vs$12,253).
E.TOPAS(ThrombolysisorPeripheralArterialSurgery)
Ourieletal.publishedtheresultsof544patientswithlowerextremitynativeorbypassgraftocclusions
of<14daysdurationrandomizedtoCDTwithr-UKversussurgery.10Inphase1,213patientscompared
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r-UK doses versus surgery, showing that 4000 IU/min of recombinant UK for 4 hours followed by
2000IU/minformax48hoursbalancedthemaximallyticeffect(71%achievementoflysisofthrombus)
withthelowestrateofbleeding.Phase2lookedat544patientswith ALI<14daysandshowedthatat
6monthsand1year,theamputation-freesurvivalratewasnotsignificantlydifferentbetweenthegroups
withsimilarmedianhospitalstays.Followedto1year,amputation-freesurvivalandmortalityremained
similar.IntheCDTgroup,bypassgraftocclusionpatientsshowedbetter amputation-freesurvivalrates
thannativevesselthrombosis.Thethrombolysismajorintracranialhemorrhageratewas12%compared
with5%inthesurgerygroup.
F.STILE(SurgeryvsThrombolysisforIschemiaoftheLowerExtremity)
Trial
The STILE investigators published the results of 393 patients with nonembolic ALI, who were
randomizedtothrombolysis(rt-PAorurokinase)orsurgerywithposthocstratificationofsymptomsinto
<14daysdurationand>14daysduration.2830%ofpatientshadischemicsymptomsfor<14days.CDT
in patientssymptomatic <14 days had lower rates of amputation, improved limb salvage, and shorter
lengthsofstaythansurgicalpatientsorCDTpatientswithsymptoms>14days.In thisgroup,rt-PAand
urokinasewere similarlyeffectiveandsafe,but rt-PA showedshorterlysis time. Forthe patientswith
symptoms>14days,thesurgicalgrouphadloweramputationratesat6months.
G.PercutaneousMechanicalThrombectomy
1.Percutaneousmechanicalthrombectomy(PMT)encompassesagroupoftechniquesanddevicesaimed
atremovingthrombuswithacombinationofmechanicaldisruption,dissolution,andaspiration.Success
ofcatheter-directed thrombolysis dependsonsize,composition,location, and ageof thethrombus, as
well as inflowandoutflowfrom the lesion. Contraindications tothrombolysis mayprecludeitsusein
somepatients,andPMTrepresentsanadjunctivetherapyforclotremovalandevenfirst-linetherapyin
somecases.
2.AnunderlyingprincipalofPMTtreatmentisrecirculationwithhydrodynamicmacerationofthrombus
andremovalviaaspirationbasedontheBernoulliprincipleandVenturieffect.Therearethreeprincipal
categoriesofrecirculationforthrombusevacuation:rheolytic,ultrasonic,andmixingdevices.
3. The AngioJet rheolytic thrombectomy system (Medrad Interventional/Possis, Minneapolis, MN)
includessingleusecatheterandpumpsetswithmultiusedriveunitandfunctionstoremoveclotviahighpressuresalineinjectionatthedistalcathetertiptoformalowpressurezoneviatheBernoullieffectthat
maceratesthethrombus.Followingthis,theclotissuckedbackintothecatheterforremoval.Thissystem
is FDAapprovedforinfrainguinalarterialcasesandhasbeenshowntoaspirate>75%ofthrombusin
ALI of native vessels or grafts.29 In one experience of 21 patients with ALI (52% of who had
contraindicationstolysis),AngioJetresultedin91%removalofthrombuswith89%ofpatientsachieving
limbsalvageat6months.30Thepower-pulsespraytechnologyhasbeenreportedtohavea90%success
ratewithinfusionofthrombolyticinfusionthroughthecathetertooptimizeclotdisruptionandremoval.
29
4. Possible complications from this system include distal embolization, theoretical hemolysis with
repeatedpassesofthe device, andfluidoverloadpotential owingtocontinuousdeviceirrigation.31 In
addition,theriskofdistalembolizationremainsbutcanbemitigatedbyuseofafilter.
H.PercutaneousAspirationThrombectomy
Percutaneous aspiration thrombectomy is based on the simple concept of a negative pressure syringe
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attached to a catheter to aspiratethrombus.ThePronto catheter(Vascular Solutions,Inc, Minneapolis,
MN) is a rapid exchange aspiration thrombectomy catheter with a 0.035-in crossing profile and
hydrophilic coating. The volume of thrombus aspiration potential is limited compared with rheolytic
catheters,butthisisbalancedbythesmallprofileofthedeviceanddeliverability.Therearenoformal
studies on the use of the Pronto device in ALI, only reports in the literature of its use in managing
embolizationduringperipheralintervention.32TheExportcatheter(Medtronic,Inc,Minneapolis,MN)is
asimilarcathetertothePronto,buttherearenopublishedreportsofitsuseinALI.
I.PercuataneousUltrasonography-AssistedFibrinolysis
Percutaneousultrasonography-assistedfibrinolysiswasdevelopedasanalternativetoCDTtodecrease
the bleeding complication rate associated withthrombolytics byaugmenting enzymatic clot lysis with
low-intensity ultrasound to loosen fibrin strands and increase clot permeability to expose more
plasminogen receptors for binding.
33-35
The DUET study (Dutch randomized trial comparing standard
catheter-directed thrombolysis and ultrasound-accelerated thrombolysis for arterial thromboembolic
infrainguinaldisease)evaluatedwhetherultrasound-assistedlysiscanreducetherapytimecomparedwith
standardCDT.SixtypatientswithRutherfordIandIIaacutelimbischemia(averagedurationofischemia
being 19 days) were randomized to standard CDT or ultrasound-assisted thrombolysis. The primary
outcomemeasuredwas the durationofthrombolysisforuninterruptedflow.Theyfound thatultrasoundassistedthrombolysis showedasignificantlyfastertimetoflow restoration(17.7vs 29.5 h).36 Hourly
thrombolytic dose rate of urokinase was the same in both groups, but the ultrasound-assisted group
receivedlowertotaldoseofthrombolysisgiventheshorterinfusiontimenecessaryforflowrestoration.
DUETIIisanonrandomizedtrialbeingplanned toinvestigatelower hourlydose todecreasebleeding
risksowingtothrombolysis.
VII.SurgicalRevascularization
Ultimately, a surgical strategy using location centered approach may be necessary with an ischemic
thrombus. These include balloon catheter thrombectomy and bypass surgery, with adjunctive
endarterectomyandintraoperative lysis. Foracute limbischemia of <14 days duration, catheter-based
thrombolytic therapies are reasonable first-line treatment, but based on the TOPAS trial, surgical
revascularization is generally preferred as first-line therapy in patients with symptomatic occlusion
>14days.
VIII.ReperfusionInjury
Reperfusioninjuryisaclinicaldiagnosisthatmustbesuspectedinanypatientafterrevascularizationwho
presentswith severe pain,weakness, and decreased sensationin the affected limb. Patients should be
carefully monitored postprocedure for any change in symptoms. Laboratory result abnormalities can
includemyoglobinuriaandCKelevation.37Theanteriorcompartmentismostvulnerable,anditiscritical
toassessforperonealnervefunctionbyfootdorsiflexionandtoassessfordecreasedsensationbetween
the first and second toes. Ultimately, this is a clinical diagnosis, but measurement of compartment
pressuresconfirmsthediagnosis.Treatmentissurgicalfasciotomytodecompresselevatedcompartment
pressure.
IX.Summary
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Acutelimbischemiaisassociatedwithhighratesofhospitalmortalityandlimbloss,with15%-20%of
patients dying within 1 year of initial presentation owing to underlying morbid conditions.13 Timely
diagnosisiscriticaltolimbsalvage.Clinicalassessmentoflimbtemperature,pulses,motor,andsensory
function is necessary to classify the limb as viable, threatened, or nonviable. Administration of
intravenous unfractionated heparinis appropriate after diagnosis. Patients with aviable or marginally
threatenedlimbcanproceedtoimaging,butthosewithathreatenedlimbshouldproceedtoangiogramto
guide treatment with catheter-based therapies (thrombolysis and thrombectomy) or surgical
revascularization.
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thrombolysisandmechanicalthrombectomyforacutelower-limbischemia.CardiovascInterventRadiol.2011;34(6):1123-1136.
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19.McNamaraTO,FischerJR.Thrombolysisofperipheralarterialandgraftocclusions:improvedresultsusinghigh-doseurokinase.AJRAm
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C H A P T E R 1 7
HybridLowerExtremityRevascularization
SameerNagpalMD
CarlosMenaMD,FACC,FSCAI
BauerE.SumpioMD,PhD
I.Introduction
II.PreprocedureAssessment
A.ImagingandLabs
B.Drugs
III.ConcomitantIliacandCommonFemoralArterialDisease
A.Endarterectomy
B.EndovascularTechnique
IV.ConcomitantIliacandInfrainguinalDisease
V.SevereBilateralIliacDisease
VI.InfrainguinalMultilevelDisease
VII.CommonFemoralandInfrainguinalDisease
VIII.HybridRevascularizationOutcomes
IX.Summary
I.Introduction
Patients with chronic limb ischemia often have multilevel aortoiliac and infrainguinal disease. These
patientsusuallyrequirecompleterevascularizationtoalleviatesymptomsandimprovewoundhealingor
prevent amputationinthe case ofcritical limbischemia. While some lesions are besttreatedusing an
endovascular catheter based approach, others, such as flow-limiting atherosclerosis of the common
femoralartery,arebestsuitedforsurgicalmanagement.Patientsrequiringbothmodalitiesofintervention
areoftentreatedinastagedfashion,butthereisincreasingappreciationforusingasingle,simultaneous,
hybrid procedurewhichmakesup5%-21% ofcurrentlower extremity revascularizationprocedures.
1
Hybridprocedurescombinewire- and catheter-based therapies with surgeryintoasingleprocedureto
improverevascularizationcompletenessandefficiencyandpatientsatisfactionandreducetheoverallrisk
associatedwithperformingmultipleprocedures.
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II.PreprocedureAssessment
A.ImagingandLabs
Preprocedure planning withnoninvasive imaging such as computed tomographyangiography, magnetic
resonance angiography, or invasive angiography assists the operator in developing an optimal hybrid
surgical and endovascular plan. Specifically, appropriate operatory or interventional laboratory
requirements, patientpositioning,suitability of variousaccess points, appropriateequipmentselection,
and any case-specific anatomic complexities can be reviewed before intervention. Previously, less
complex lesions were targeted for endovascular interventions with surgical management reserved for
morecomplexdiseaseorlengthychronictotalocclusions.However,withadvancementinendovascularbased technologies and operator skill set, percutaneous interventionsare often used evenfor complex
Trans-AtlanticIntersocietyConsensus(TASC)CorDlesions.
B.Drugs
Typically,hybridproceduresareperformedwithgeneralanesthesiainanoperatingroomwithamobile
fluoroscopy unit capable of performing digital subtraction angiography. Dual-antiplatelet loading is
usuallydelayeduntilaftertheinterventiontolowerimmediatesurgicalbleedingrisk,especiallyincase
ofunforeseencomplications.Preoperativeprophylacticintravenousantibioticsaretypicallyprovidedto
preventinfection.Aftersurgicalexposureofthevesselsandbeforevesselclampingorsheathinsertion,
intravenousheparinisadministeredtotargetanactivatedclottingtimeoftwicetheupperlimitofnormal.
III.ConcomitantIliacandCommonFemoralArterialDisease
A.Endarterectomy
In the case of occlusive aortoiliac disease extending into the ipsilateral commonfemoral bifurcation,
surgical common femoral endarterectomyis typicallyperformed first. A longitudinal common femoral
arteriotomyismadeandcanbeextendedproximallyintothedistalexternaliliacarteryordistallyintothe
proximal superficial and deep femoral arteries just beyond the bifurcation. After endarterectomy is
performed and the obstructing plaque is removed, the arteriotomy is closed with a patch angioplasty
(usingautogenousveingraftorsyntheticorbiologicmaterial)orinterpositionsyntheticgraft.
B.EndovascularTechnique
Following surgical endarterectomy, the inflow iliac lesion is then approached via endovascular
technique. Contralateral standard retrograde femoral access is obtained percutaneously, and a distal
aorticangiogramis pursuedifonehasnotbeenobtainedpreviously. Forlesions involvingthe external
iliacartery,contralateralaccessmaybesufficientifthereisenoughlengthoverthebifurcationtoallow
positioningofalongsheathwithadequatesupport.Forlesionsinvolvingtheproximalorostialcommon
iliacartery,asheathisplacedintotheipsilateralsurgicallyexposedandreconstructedfemoralarteryto
perform the endovascular intervention, which typically is successful using solely a wire and catheter
technique for lesion crossing. Bare-metal balloon-expandable stents are generally used within the
commoniliacsegmentgiventheirstrongerradialforceanduseinostiallesions,whereasself-expandable
bare-metalstentsareoftenusedwithintheexternaliliacsegment,particularlyintortuousvessels,given
theirconformability.
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IV.ConcomitantIliacandInfrainguinalDisease
Iliacarterystentingmaybecombinedwithinfrainguinalbypassinasinglehybridprocedure.Inthiscase,
surgicalcutdownisusedtoexposethecommonfemoralartery,throughwhichretrogradestentingofthe
ipsilateral iliac artery is performed via an endovascular approach. After successful restoration of
adequate inflow, infrainguinal bypass is then carried out in the usual surgical fashion, favoring
nonreversed saphenousveingraft(over syntheticgrafting)fromthecommonfemoralarterytoaboveor
belowthekneevesselsasdictatedbythepatient’sanatomyandatheroscleroticdiseaseburden.
V.SevereBilateralIliacDisease
Patientswithunilateralcompleteocclusionoftheiliacsystemandcontralateraliliacdiseaseamenableto
catheter-basedtherapymayundergostentingofthecontralateral iliacarteryfollowed bycross-femoral
bypassduringasinglehybridprocedure.Thishybridprocedureobviatestheneedforanaorto-bifemoral
bypass,whichcarriesalargeroperativemorbidityandmortality,particularlyinhigherriskpatients.The
hybrid procedurebegins withsurgical exposure of thefemoral arteries ipsilateral tothetargeted iliac
lesion.After retrograde sheath insertionand stenting of the iliac lesion, cross-femoral bypass can be
performed beginning with the synthetic graft anastomosis to the already exposed femoral artery and
tunnelingofthegraftacrossthepelviswithendtosideanastomosistothecontralateralfemoralartery.
VI.InfrainguinalMultilevelDisease
Inpatientswithmultilevelinfrainguinaldiseasewhodonothaveadequateveinsforasinglelongbypass
graftandinwhomcatheter-basedmanagementfailedtoprovideadequateoutflow,endovasculartherapy
of superficial femoral arterial disease can be combined with distal popliteal to calf vessel bypass
grafting. In such cases, percutaneous access of the contralateral femoral artery can be used for the
endovascularportionoftheprocedureunlesscommonfemoralendarterectomyisalsobeingperformed,in
whichcasedirectantegradeaccessviathearteriotomyispreferred.
VII.CommonFemoralandInfrainguinalDisease
The combination of common femoral and distal infrainguinal disease may be treated with femoral
endarterectomytobeginwithasdescribedabove,followedbyantegradesheathinsertionintotheexposed
vessel. Antegrade access allows forbetter support,feedback, andpushability ofwires, catheters, and
otherdevices,whichmaybenecessaryfordistalbelow-the-kneelesionsorchronictotalocclusionswith
calcifiedproximalcaps.
VIII.HybridRevascularizationOutcomes
Hybrid interventions are becoming increasingly common place given their benefits as summarized in
Table17.1alongwithpreliminarydatatosuggesttheirnoninferioritytostagedinterventionswithrespect
tomajor outcomes andoverall risk.Several studies have demonstratedlimb salvage andintervention
patency rates to be equivalent for hybrid procedures compared with lone endovascular or surgical
treatment strategies. One large retrospective study of 654 patients undergoing lower extremity
revascularization with endovascular, surgical, or hybrid strategies showed comparable 3-year limb
salvagerates inexcess of80% and similar primaryandsecondary patencyrates along withlongterm
survival.2A secondstudyof 162 patients (248 limbs) withiliofemoral occlusive disease undergoing
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either hybrid iliac stenting and common femoral endarterectomy or surgical aortoiliac and femoral
reconstructiondemonstrated similar 30-day mortality (1.1% vs 1.4%,P = .85)andprimary patencyat
3years(91%vs97%,P=.29)whichwasmaintainedregardlessofTASClesionstatus. Overalllongtermsurvivalwaslowerforthoseundergoinghybridrevascularization(40%vs74%,P=.007),likely
owing to the higher risk cardiac status of the patients undergoing hybrid revascularization.3 Finally,
Chang etal., retrospectively studied 171 patientsundergoingsimultaneousiliac artery stenting or stent
grafting with common femoral endarterectomy. Completeiliac arteryocclusion was present in 41%of
cases,andstentgraftswerealsousedin41%ofcases.Theimmediatetechnicalsuccessratewas98%.
Five-year primary and secondary patency rates were 60% and 98%, respectively. Endovascular
reinterventionwasrequiredin14%andinflowsurgicalbypassin10%ofpatients.
4
Table17.1
BenefitsofHybridLowerExtremityRevascularization
Completeinflowandoutflowrevascularizationwithoutdelayinherentinstagedprocedures
Immediatesurgicalback-upincaseoffailedorcomplicatedendovascularattempt
Reducedfemoralaccesssitecomplicationsincasesofsurgicalcutdown
Reducedoverallprocedureandanesthesiarelatedrisks
Improvedcost-effectivenessbyreducinghospitalizationlength
Immediateangiographicflowassessmentofsurgicaltreatment/graft
IX.Summary
Patientswithchroniclimbischemiaandmultilevelocclusivediseaseareoftentreatedwithacombination
of endovascular and surgical techniques to improve claudication or for limb salvage in critical limb
ischemia.Performingtheseproceduresinastagedfashioncandelaycare,reducepatientsatisfaction,and
increaseprocedure-andanesthesia-relatedrisks.Consolidatingtreatmentintoasinglehybridprocedure
incorporating both endovascular and surgical therapies provides complete revascularization with
improved efficiency and patient satisfaction, lower cumulative procedure-related risks and costs, and
equivalentlimbsalvageoutcomestoastagedapproachbasedontheavailabledata.Carefulpreprocedure
planning is necessary and often requires advanced noninvasive imaging to define anatomy and other
complexities.
References
1.EbaughJL,GagnonD,OwensCD,ConteMS,RaffettoJD.Comparisonofcostsofstagedversussimultaneouslowerextremityarterial
hybridprocedures.AmJSurg.2008;196(5):634-640.
2.DosluogluHH,LallP,CherrGS,HarrisLM,DryjskiML.Roleofsimpleandcomplexhybridrevascularizationproceduresfor
symptomaticlowerextremityocclusivedisease.JVascSurg.2010;51(6):1425-1435.e1.
3.PiazzaM,RicottaJJ,BowerTC,etal.Iliacarterystentingcombinedwithopenfemoralendarterectomyisaseffectiveasopensurgical
reconstructionforsevereiliacandcommonfemoralocclusivedisease.JVascSurg.2011;54(2):402-411.
4.ChangRW,GoodneyPP,BaekJH,NolanBW,RzucidloEM,PowellRJ.Long-termresultsofcombinedcommonfemoral
endarterectomyandiliacstenting/stentgraftingforocclusivedisease.JVascSurg.2008;48(2):362-367.
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