The Role of Hybrid Femoropopliteal Revascularization in High-risk (ASA 3-4) Patients: A Decade of Dual Center Clinical Experience

Background: The present chapter focus on eventual clinical benefit of hybrid revascularizations gathering common femoral artery (CFA) endarterectomy coupled to femoropopliteal endovascular recanalization in high-risk ASA Class 3-4 patients having severe infrainguinal multilevel occlusive disease.

Materials and Methods: From January 2009 until November 2019, a series of 205 hybrid infrainguinal interventions performed in 178 ASA Class 3-4 patients (Rutherford category 2-6 ischemic presentations) were retrospectively analyzed. Patient demographics, specific risk factors, technical characteristics, parallel to patency, limb salvage and survival results were examined during a mean 44.9 months of follow-up. In the whole, long (>15 cm) and intermediate (5-15 cm) CTO were present in 198 (96%) of all ischemic limbs, in parallel to severe CFA atherosclerotic disease. Two or three runoff tibial trunks were evinced in 172 (84%) cases, while moderate-to-severe arterial calcifications were present in 78 (38%) cases.

Results: Inasmuch the surgical approach was successful in all cases, the endovascular step of all hybrid interventions was technically rewarding in 190 (93%) cases. The postoperative ABI improved (> 1.5) in 75% of cases, while clinical presentations gained at least one Rutherford category in 182 (89%) limbs. The postoperative 30-day mortality rate noted in this specific “high-risk” group of patients was 3.3%. The mean hospital stay was 6.2 days (3-14 days).

Primary patency estimates revealed 88% (95% CI 84% to 91%) and 66% (95% CI 56% to 75%) at 12 and 60 months, while limb salvage was 93% (95% CI 88% to 95%) and 80% (95% CI 72% to 86%) at the same time intervals, respectively.

Global risk factors alike smoking (p=0.003) and female gender (p=0.001), together with CTOs length (>15 cm / p=0.016), severe calcifications (p=0.049), poor tibial runoff (p=0.018, and p=0.001 for 1, and 0 permeable trunks), the GLASS/FP grade “4” lesions (p=0.039), and the stent length (>6 cm / p=0.001), showed parallel negative influence on primary patency.

Conclusion: Hybrid infrainguinal revascularization may offer beneficial option for treatment options in high-risk ASA 3-4 patients. Careful patient selection and technique planning appear essential for achieving appropriate arterial reconstruction and limb salvage outcome.