Vascular and endovascular combined procedures in lower limbs arterial reconstruction.

Objective: The association of vascular and endovascular procedures, in patients with multifocal obstructive disease of the lower limbs, gives the opportunity to treat in a single step multi-segmental lesions which were previously treated in more demanding open procedures. Methods: From January ‘99 to May ‘05, thirty-five patients, 29 males and 6 females, with chronic occlusive arterial disease of the lower limbs (3rd–4th Fontaine stage) were submitted to combined vascular and endovascular procedures. In 25 patients (71.5%) (Group 1) a femoro-popliteal/pedidial bypass was carried out after PTA/Stenting of the iliac arteries, while in the 10 patients (28.5%) (Group 2) the endovascular procedures were performed following the surgical approach (a femoropopliteal bypass). The prosthetic material was autologous saphenous vein in 23 patients (65.7%), PTFE EXS in 8 (22.8%) and a biological graft in the remaining 4 (11.5%). In the group 1 after iliac stenting a fem-pop subarticular bypass was carried out in 19 (76%), a fem-pop suprageniculate in 4 (16%), a fem-pop + jump on the posterior tibial in 1 (4%) and a superficial femoral-pedal in the last one (4%). In the other group the fem-pop subarticular bypass was followed by a PTA of the tibial vessel in 8/10 cases (80%) and by a tibial stenting in 2 cases (20%). The follow-up was from 3 to 65 months and the patients were submitted to routine controls by means of Duplex scan. MRangiography or a dye angiography were performed in complicated cases. Results: One patient was lost to follow-up and none died. Two (8%) iliac stents became occluded and the sudden onset of an acute ischemia of the limb required in both cases an aorto-femoral bypass on emergency. The occlusion of the tibial stent in one patient (10%) was no clinical relevant, and the failure of the PTA procedure in other two (20%) with the reocclusion of the tibial arteries was followed by thight amputation; Occlusion of the femoro-popliteal bypass occurred in 6 of 25 patients of group 1(24%) and in 3 of 10 of group 2 (30%). The overall patency rate was 74.3%. Conclusion: Combination of the vascular and endovascular surgery is effective and durable in terms of patency and complication rate. A revision of the international literature shows no codified protocols on combination so that this choice depends only on the subjective surgeon's experience. In our opinion the good results obtained depends also on the patient's selection and on the arterial disease morphology.