Archive \ Volume.15 2024 Issue 4

Hybrid Revascularization in Treatment of Patients with Multilevel Vascular Lesion of Lower Extremities of Atherosclerotic Genesis

INTRODUCTION

One of the most difficult and unresolved problems in vascular surgery is the treatment of chronic critical ischemia of the lower extremities (CCILE) [1, 2]. This disease accounts for up to 15-20% of the total number of peripheral artery diseases [3-5].

It should be noted that if adequate treatment is not carried out, then within five years only 30% of patients with CCILE manage to save their limbs [6, 7]. The remaining 52% of patients undergo amputations, and 18% of patients die from complications of CCILE [8-11]. Thus, recent studies revealed that the frequency of CCILE amputation remains high [12]. In European countries, 150 to 280 lower limb amputations per million people are performed annually [13, 14]. At the same time, the number of amputations in people of working age is growing [15, 16].

The disability of the able-bodied population leads to huge costs for the medical and social rehabilitation of such patients [17, 18]. Currently, more than 800 million euros are allocated annually to solve this problem in Europe [19]. At the same time, the costs of hospital treatment of a patient after amputation amount to more than 10 thousand euros per patient [20].

Choosing the optimal treatment method for lower limb ischemia is an urgent task that requires a deep understanding of both open and endovascular therapies [21, 22]. Traditionally, open methods such as aorto-femoral bypass surgery and other surgical interventions are used to restore blood flow [23-26]. However, with the development of technology, endovascular procedures have appeared, for example, angioplasty and stenting [27-29]. In this regard, there is a need for a comparative analysis of these approaches, as well as the effectiveness of their combination.

Thus, this study aimed to evaluate the results of "hybrid operations" in patients with multilevel lesions of the lower extremities.

MATERIALS AND METHODS

For this study, 26 patients were selected who underwent "hybrid operations" for the period from 2023 to 2024. The operations were performed in the conditions of the vascular surgery department of the local City Hospital. Ultrasound Dopplerography, ultrasound duplex scanning, and CT angiography were used to study the main arteries of the lower extremities [30, 31]. The operations were performed in patients with multilevel lesions of the arteries of the lower extremities with the CCILE clinic and the ineffectiveness of the known methods of direct revascularization [32-34].

All patients were divided into two groups. In the first group, the ilio-femoral segment underwent isolated open reconstruction (25 patients). In the second group hybrid revascularization of the same segment was performed with multilevel lesions of the arteries of the lower extremities (26 patients). By gender, the patients were distributed as follows: 19 (73.1%) patients were men, and 7 (26.9%) were women, which corresponds to recent studies on the correlation between sex and CCILE [35, 36]. The average age of patients was 68.5 ± 4.5 years, with many concomitant diseases, further aggravating the general condition of the patient, and preventing traumatic interventions (Table 1).

In 15 patients, chronic lower limb ischemia of the III degree was observed, in 11 – IV degree according to the Fontaine-Pokrovsky classification [37]. The following types of isolated open reconstruction of the ilio-femoral segment were performed (n=25):

1. Endarterectomy of the ilioemoral segment + femoral-popliteal bypass surgery – 7 (28%).
2. Profundoplasty + femoral-popliteal bypass surgery – 4 (16%).
3. Profundoplasty + femoral-deep-hip bypass surgery – 5 (20%).
4. Endarterectomy + superficial femoral-tibial bypass surgery – 3 (12%).
5. Endarterectomy of the ilioemoral segment + superficial femoral-tibial bypass surgery with the formation of a fistula in the distal anastomosis area - 2 (8%).
6. Endarterectomy of the common iliac artery + cross femoral-femoral bypass surgery – 1 (4%).
7. Endarterectomy from the distal part of the popliteal artery + femoral-popliteal bypass surgery – 1 (4%).
8. Subclavian-iliac bypass + femoral-popliteal bypass + profundoplasty – 1 (4%)
9. Cross femoral-femoral bypass + femoral-popliteal bypass – 1 (4%).

The results of surgical interventions were evaluated according to the scale of changes in clinical status according to the Russian Society of Angiologists and Vascular Surgeons [38].

The following types of "hybrid operations" were performed (n=26):

1. Stenting of the ilio-femoral segment + femoral-popliteal bypass surgery – 5 (19.2%).
2. angioplasty of the ilio-femoral segment + femoral-popliteal bypass surgery – 5 (19.2%).
3. angioplasty of the ilio-femoral segment + femoral-hip bypass surgery – 4 (15.4%).
4. Endarterectomy of the ilio-femoral segment + stenting – 1 (3.8%).
5. Endarterectomy of the ilio-femoral segment + angioplasty – 2 (7.7%).
6. Stenting of the common iliac artery + cross femoral-femoral bypass surgery – 2 (7.7%).
7. Stenting of the ilioemoral segment + endarterectomy of the superficial femoral artery - 1 (3.8%).
8. femoral–popliteal bypass surgery + angioplasty of the arteries of the tibia - 1 (3.8%).
9. endarterectomy of the superficial femoral artery arteries + stenting of the anterior tibial artery PBBA – 1 (3.8%)
10. angioplasty of the common iliac artery + thrombectomy from the femoral-popliteal shunt – 1 (3.8%).
11. thrombectomy from the femoral-popliteal shunt + angioplasty of the popliteal artery – 2 (7.7%).
12. Stenting of the ilioemoral segment + thrombectomy from the femoral-popliteal shunt - 1 (3.8%).

RESULTS AND DISCUSSION

The results of the evaluation of surgical interventions are presented in Table 2.

The results of the complication analysis are presented in Table 3.

In the immediate postoperative period, on a control angiogram and ultrasound examination, there was an improvement in peripheral hemodynamics. Complete patency of the reconstruction zones was noted as well. A month later, in patients of the first group with chronic ischemia of the III degree, relief of pain syndrome at rest was noted, with an increase in the pain-free walking distance. In the second group, the absence of positive dynamics was noted in 5 patients. In patients with grade IV ischemia in the second group, there was a decrease or relief of pain syndrome, except for two patients, due to the ineffectiveness of balloon angioplasty of the tibial arteries, shunt thrombosis developed, and therefore amputation had to be performed at the level of the lower third of the thigh. No deaths were observed. In patients with grade IV ischemia in the first group, an increase in the clinic of critical ischemia was observed, due to thrombosis of the autovenous shunt and vascular prosthesis in 5 cases. Also in the same group, the operation was complicated by myocardial infarction in three patients, while in group 2 this complication was absent.

CONCLUSION

1. Performing open methods of revascularization of the distal bed is possible only in the presence of adequate outflow through the arteries of the lower leg, which has the advantage of "hybrid operations".
2. The traumatism of "hybrid operations" is less, which is better tolerated by patients with severe concomitant diseases.
3. Hybrid revascularization operations are the method of choice in patients with chronic lower limb ischemia of the IV degree, which contribute to faster healing of trophic disorders and preservation of the limb for a longer period.

• complete revascularization of the ischemic limb occurs in one session;
• open surgery can eliminate inadequate endovascular results and vice versa;
• potential infectious complications of long-term open intervention or two separate interventions are minimized;
• reducing the risks of anesthesia complications, especially in high-risk patients;
• the hospital stay has been shortened;
• primary patency and secondary patency have the same results as with open surgery.

ACKNOWLEDGMENTS: None

CONFLICT OF INTEREST: None

FINANCIAL SUPPORT: None

ETHICS STATEMENT: All patients signed a volunteer agreement for participation in the experiment. Copies of agreements are available upon request from the corresponding author.