[Hybrid interventions for atherosclerotic lesions of the lower limb arteries]

Treatment of multilevel atherosclerotic lesions of the lower limb arteries is an acute problem in modern medicine. There is no a single treatment algorithm. Hybrid technologies are one of the possible treatment options. There are reasonable assumptions that these technologies can at least partially solve this problem. Minor trauma is an undoubted advantage of hybrid technologies. Therefore, these approaches are advisable in severe patients with various comorbidities and contraindications for traditional methods. Therefore, analysis of hybrid methods is of great interest for cardiovascular surgeons. Hybrid method is now recognized as one of the most effective and minimally traumatic treatment for patients with atherosclerotic lesions of the lower extremities.

The Role of Early Revascularization and Biomarkers in the Management of Diabetic Foot Ulcers: A Single Center Experience

Diabetic neuropathy and Peripheral Arterial Disease (PAD) are the main etiological factors in foot ulceration. Herein, we report our experience of diabetic foot ulceration (DFU) management, with an analysis of the relationship between the rate of lower extremity amputation, in persons with infected DFU, after revascularization procedures performed to prevent major amputation. This study highlights the role of different biomarkers, showing their usefulness and potentiality in diabetic foot ulcer management, especially for the early diagnosis and therapy effectiveness monitoring. A retrospective analysis, from September 2016 to January 2021, of diabetic patients presenting diabetic foot with DFU, was performed. All patients were treated with at least one vascular procedure (endovascular, open, hybrid procedures) targeting PAD lesions. Outcomes measured were perioperative mortality and morbidity. Freedom from occlusion, primary and secondary patency, and amputation rate were registered. A total of 267 patients, with a mean age of 72.5 years, were included in the study. The major amputation rate was 6.2%, minor amputation rate was 17%. In our experience, extreme revascularization to obtain direct flow reduced the rate of amputations, with an increase in ulcer healing.

The effect of the stented iliac lesions TASC-II C, D on the femoropopliteal bypass patency: Propensity score-matched observational study

INTRODUCTION

Concurrent stenting of complex iliac lesions during infrainguinal bypasses can increase the complexity of a case and impact outcomes.

OBJECTIVE

Our aim was to evaluate the effect of inflow stenting of TASC-II C, D iliac lesions on femoropopliteal bypass patency.

METHODS

A retrospective observational cohort study of patients who underwent femoropopliteal bypass with TASC-II C, D iliac artery stenting (hybrid group) or without inflow lesions (non-hybrid group) was conducted. After propensity score matching, 120 patients were included in the non-hybrid group and 60 patients in the hybrid one. The median follow-up was 432 (193; 1313) days in the hybrid group and 472 (196; 1376) days in the non-hybrid group (p = 0.94).

RESULTS

No significant differences were found between the groups in 30-day morbidity and serious adverse events. At 3 years, primary and secondary bypass patency for the hybrid group and non-hybrid group were 62.2% versus 59.9% (p = 0.36) and 63.7% versus 64.3% (p = 0.077), respectively. The primary patency of the iliac stents in patients of the hybrid group was 95% at 3 years. The estimated hazard ratio for primary patency for hybrid versus non-hybrid was 0.77, with 90% CI: 0.50-1.21; the noninferiority upper bound being 1.31, which corresponds to a 10% additive noninferiority margin for probabilities. The 3 years of freedom from amputation in patients with chronic limb-threatening ischemia was 94.1% and 75.0% in the hybrid and non-hybrid groups, respectively (p = 0.09).

CONCLUSION

The outcomes of the femoropopliteal bypass in hybrid surgery supplemented with stenting of TASC-II C, D iliac lesions was similar to femoropopliteal bypass with intact inflow arteries.

[Endovascular revascularisation in patients with necrotic wounds and extended infrainguinal arterial disease]

OBJECTIVE

To report own experience of endovascular interventions in patients with extended occlusive lesion (TASC II D) of the femoral-popliteal and tibial arteries and concomitant purulent-necrotic wounds.

MATERIAL AND METHODS

We have analyzed literature data and own experience of endovascular interventions in patients with extended occlusive lesion (TASC II D) of the femoral-popliteal and tibial arteries and concomitant purulent-necrotic wounds.

RESULTS

Endovascular strategy is preferable in a certain subgroup of patients with extended infrainguinal lesions.

CONCLUSION

Considering own data, we assumed the need for routine correction of outflow pathways (simultaneous angioplasty of at least 2 tibial arteries). Primary results are encouraging, but further research is required.

Single staged hybrid approach for multilevel aortic-iliac-femoral-popliteal disease

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Multilevel peripheral arterial disease in diabetic patients is cause of amputation.

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Herein we report a case of critic limb ischemia addressed by hybrid procedure.

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Hybrid procedure outcomes seem to be as good as with open revascularization.

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Hybrid procedure show less morbidity and shorter intensive care and hospital stay.

Introduction

Multilevel peripheral arterial disease (MPAD) is the main cause of critic limb ischemia (CLI). Vascular interventions are required to increase distal blood flow and reduce the risk of lower limb amputation.

Presentation of case

We report a case of complex hybrid revascularization in a patient presenting a Rutherford V MPAD involving the infrarenal aorta, iliac, femoral and popliteal segments. The simultaneous hybrid intervention consisted of an endovascular aortic stent-graft placement and a surgical above-the-knee prosthetic femoro-popliteal bypass. In the same operation a renal stenting was performed due to a significant renal artery stenosis associated to a systemic hypertension non-responder to medical management.

Discussion

Hybrid interventions can be performed simultaneously or staged with benefit given by the complementary role of endovascular and surgical treatments allowing the correction of eventually inadequate results of both approaches. Reports of simultaneous hybrid treatments are limited but, despite the complexity of such procedures, primary success rate is reported high. Also in the reported case, a complex simultaneous treatment in a patient presenting MPAD in association to a significant and symptomatic renal artery disease was feasible in the same operation.

Conclusion

Hybrid procedure are safe with high degree of efficacy in terms of revascularization procedure, reduced morbidity and shorter intensive care and hospital stay. In our experience, the use of hybrid procedure is technically feasible and allowed the treatment of MPAD with a good outcomes.

Review of 20 years of vascular surgery research in Australasia: Defining future directions

Objectives

High-quality research is fundamental to the advancement of surgical practice. Currently, there is no quantitative assessment of the research output of vascular surgeons in Australia and New Zealand. By conducting this bibliometric analysis, we aim to provide an objective representation of the trends in vascular surgery and guide future research.

Methods

A list of all current vascular surgeons in Australia and New Zealand was compiled from the Royal Australasian College of Surgeons 'Find a Surgeon' website tool and correlated with the Australia and New Zealand Society for Vascular Surgery database. A Scopus search of each surgeon's author profile over the last 20 years was conducted.

Results

In total, 2120 articles were published by 208 Australasian vascular surgeons between 1998 and July 2018, with an overall increase in publications over time. Audits or case series were the most published type of study and only 8% of the publications were of high-level evidence. The most popular topics were thoracoabdominal aortic pathologies (24%), followed by peripheral arterial disease (15%). Chronological analysis illustrates an increasing volume of peripheral arterial disease research over time and there is a clear trend towards more endovascular and hybrid surgery publications. The top 10 (5%) highest publishing authors by h-index account for 41% of all publications and 49% of all citations and are also responsible for producing significantly more high-level evidence research.

Conclusion

Australasian vascular surgeons have made a significant contribution to medical research. However, the majority of these articles are of low-level evidence. In this time, there has been an increasing number of publications on endovascular and hybrid surgery in keeping with the trend in clinical practice. These areas, as well as research regarding peripheral arterial disease, show potential for high-evidence research in the future.

National trends of hybrid lower extremity revascularization in the ACS-NSQIP database

Objectives

Despite reports of increasing use of hybrid surgery for lower extremity revascularization in Europe, little is known about the performance of hybrid procedures in the U.S. This study aims to investigate contemporary national trends in frequency and operator distribution of hybrid lower extremity revascularization and compare the perioperative outcomes of independent vascular surgeons and other surgical specialists. We hypothesized that hybrid procedures are increasingly performed, and independent vascular surgeons have superior outcomes compared to other surgical specialists.

Methods

The 2005–2015 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was used to identify patients undergoing open or hybrid lower extremity revascularization based on Current Procedural Terminology codes. Only patients treated for peripheral artery disease, based on International Classification of Diseases codes-9, were included. A trend of yearly hybrid lower extremity revascularization compared to open lower extremity revascularization was obtained. The most commonly performed hybrid procedure was identified as well as the specialties of the primary operators. Operators were categorized as “independent vascular surgeons” and “other surgeons” if the primary operator was a non-vascular surgeon or a vascular surgeon assisted by a second specialist as part of a team. Patients undergoing this hybrid lower extremity revascularization by independent vascular surgeons were selected and matched (2:1) to the patients who underwent the same procedure by other surgical specialists. Matching was based on age, gender, functional status, American Society of Anesthesiologists classification, transfer status, emergent surgery, and indication. The characteristics and perioperative outcomes of those two groups were compared.

Results

The overall rate of hybrid procedures increased from 4% in 2005 to 14% in 2015 ( p < 0.0001). During this period, vascular surgeons independently performed 92.9% of all hybrid surgeries, with no significant change in the yearly trend ( p = 0.15). Femoral endarterectomy with retrograde aortoiliac intervention was identified as the most common procedure, accounting for 35.7% and 33.3% of hybrid lower extremity revascularization performed by independent vascular surgeons and other surgeons, respectively. After propensity matching, there were 212 patients treated by independent vascular surgeons and 106 patients treated by other surgeons, with no significant difference in demographics or comorbidities. There was no difference between independent vascular surgeons and other surgeons in mortality (1.4% and 2.8%, respectively, p = 0.30), overall morbidity (19.3% and 18.9% respectively, p = 0.91), and other complications.

Conclusion

Hybrid lower extremity revascularization for peripheral artery disease has been increasingly used and is performed primarily by independent vascular surgeons. Simple hybrid procedures may be performed safely by vascular surgeons as well as other trained surgical specialists.

Hybrid surgery for bilateral lower extremity inflow revascularization

OBJECTIVE

Aortobifemoral (ABF) bypass is the preferred method of bilateral inflow revascularization, with axillobifemoral (AXBF) bypass reserved for high-risk patients. Hybrid (HYB) surgery in the form of femorofemoral bypass and retrograde endovascular aortoiliac intervention is increasingly being used to achieve the same goal. This study compared the perioperative outcomes of HYB surgery with traditional surgery for bilateral inflow revascularization.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program files for the years 2012 to 2015 were reviewed, and all patients undergoing ABF bypass, AXBF bypass, and HYB surgery (femoral-femoral bypass and retrograde endovascular intervention) were included. Patients' demographics, comorbidities, and outcomes were compared between the three groups. A propensity-matched analysis was subsequently performed to compare HYB surgery with ABF bypass only. The χ² test and analysis of variance with post hoc analysis were conducted to evaluate between-group differences in risk factors and outcomes. SPSS statistical software (IBM Corp, Armonk, NY) was used.

RESULTS

There were 1426 patients (ABF bypass, 976; AXBF bypass, 257; HYB surgery, 193). There were significant differences in the three populations of patients, with ABF bypass patients significantly more likely to have age <70 years (ABF bypass, 84.2%; AXBF bypass, 49.8%; HYB surgery, 58%; P < .001) and more likely to be independent (ABF bypass, 98%; AXBF bypass, 89.1%; HYB surgery, 93.2%; P < .001). Patients undergoing AXBF bypass were significantly more likely to be treated for critical limb ischemia (ABF bypass, 46.5%; AXBF bypass, 72.4%; HYB surgery, 51.8%; P < .001) under emergent conditions (ABF bypass, 0.9%; AXBF bypass, 5.1%; HYB surgery, 3.6%; P < .001). There was no difference in mortality between the three groups (P = .178). After propensity matching, a total of 571 patients with ABF bypass were compared with HYB surgery patients. HYB surgery patients had significantly less pneumonia (ABF bypass, 8.7%; HYB surgery, 1.6%; P < .001), unplanned intubation (ABF bypass, 7.7%; HYB surgery, 3.1%; P = .032), cardiac arrest (ABF bypass, 3.7%; HYB surgery, 0.5%; P = .025), transfusion (ABF bypass, 44.4%; HYB surgery, 18.1%; P < .001), and composite morbidity (ABF bypass, 55%; HYB surgery, 32.6%; P < .001). Patients undergoing ABF bypass had significantly higher mortality (ABF bypass, 4.2%; HYB surgery, 1%; P = .043) and 30-day reoperation (ABF bypass, 17.5%; HYB surgery, 9.3%; P = .009) and longer total hospital length of stay (ABF bypass, 9.79 ± 10.69 days; HYB surgery, 5.79 ± 9.72 days; P < .001). There was no difference in major amputation (P = .607) and readmission (P = .495) between the two groups.

CONCLUSIONS

ABF bypass is the most common surgery for bilateral lower extremity revascularization in the American College of Surgeons National Surgical Quality Improvement Program database and continues to have good outcomes. In selected patients, HYB surgery was associated with improved perioperative, 30-day outcomes compared with ABF bypass.

Comparison of hybrid procedure and open surgical revascularization for multilevel infrainguinal arterial occlusive disease

Objective

To compare outcomes of hybrid (combined surgical and endovascular) procedures (HYBRID) with open surgical reconstructions (OPEN) in patients with multilevel infrainguinal artery occlusive diseases.

Design

Case series study with retrospective analysis of prospectively collected nonrandomized data.

Methods

Between 2008 and 2012, 64 patients underwent OPEN and 43 underwent HYBRID. Patient characteristics, technique success, clinical improvement, and procedure-related morbidity were reviewed and compared. Patency rates and limb salvages were analyzed and compared using Kaplan–Meier life tables. Cox regression analyses were used to assess the influence of various risk factors on primary patency.

Results

HYBRID patients were older and presented with worse New York Heart Association function compared with OPEN patients. The increase in the ankle-brachial index and improvement of Ruthford category after procedures were equivalent between two groups, but HYBRID patients had shorter hospital length of stay (7.6±12.0 versus 15.5±17.3; P= 0.018) and less overall perioperative morbidity (12% versus 28%; P=0.042) compared with OPEN patients. No statistically significant difference in 36-month primary (47.1%±7.1% versus 50.1%±9.4%; P=0.418), assisted primary (57.0%±7.9% versus 62.4%±9.2%; P=0.517), or secondary (82.0%±6.8% versus 83.1%±7.3%; P=0.445) patency was seen between the two groups. Limb salvage rates of HYBRID vs OPEN at 3 years were similar (76.3%±9.3% versus 80.4%±8.2%; P=0.579). Critical limb ischemia was a negative predictor of long-term patency of patients in both the HYBRID and OPEN groups (P=0.012 and P<0.001, respectively), and the presence of diabetes and renal insufficiency were another two independent predictors of decreased primary patency for HYBRID (P=0.017 and P=0.019, respectively).

Conclusion

Multilevel infrainguinal artery occlusive diseases could be treated by hybrid procedure, with shorter hospitalization, less perioperative morbidity, and similar early- and long-term efficacy compared with open revascularization. A hybrid procedure should be considered for patients with high surgical risk, but critical limb ischemia, diabetes, and renal insufficiency could compromise its long-term patency.