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.