Combined Percutaneous Endovascular Iliac Angioplasty and Infrainguinal Surgical Revascularization for Chronic Lower Extremity Ischemia: Preliminary Result

Abstract

The purpose of this study was to evaluate the efficacy of combined ipsilateral percutaneous iliac angioplasty and open infrainguinal surgical techniques for the treatment of patients with multilevel arterial occlusive disease. Combining two types of approaches in the peripheral vascular field is a less aggressive technique and may result in excellent early patency and limb salvage rates. We report our initial experience with a combined percutaneous endovascular iliac angioplasty and infrainguinal surgical reconstruction for patients with chronic lower extremity ischemia associated with multilevel arterial occlusive disease who presented with severe (disabling) lower limb claudication that significantly reduced quality of life, as well as patients with rest pain, nonhealing ulcers, and gangrene.There were 30 patients, 20 of whom had percutaneous transluminal angioplasty (PTA) only and 10 who had PTA with a stent. The infrainguinal procedures associated with each were thromboendarterectomy with vein patch angioplasty of both the common femoral artery (CFA) (12 patients), and the popliteal artery (8 patients) and a short femoropopliteal bypass for the superficial femoral artery (SFA) after recanalization of the arterial lumen using thromboendarterectomy to shorten the bypass graft (10 patients), using a reversed saphenous vein graft. The procedures were performed from July 2007 to February 2008 at the Division of Vascular and Endovascular Surgery, Al-Hussein University Hospital (Al-Azhar Faculty of Medicine, Cairo, Egypt).The study included 30 patients, 17 males and 13 females, with a mean age of 54 years (range 42-72) who underwent both combined ipsilateral percutaneous endovascular iliac angioplasty and open surgical treatment of both femoral (ie, the CFA or the SFA) and popliteal occlusive diseases. Indications were claudication that reduced quality of life after failure of conservative medical treatment in 14 patients (46.6%), critical limb ischemia in 8 patients (26.7%), and tissue loss, nonhealing ulcers, and gangrene in 8 patients (26.7%). Initial technical and hemodynamic success was achieved in 100% of cases. Clinical success was achieved in 96.7% of cases after 6 months, and clinical failure was observed in 3.3% of cases owing to occlusion of the short femoropopliteal bypass graft. Good hemodynamic results were observed in 74.9% of cases as the mean postoperative ankle-brachial index remained elevated to 1.03 +/- 0.1 and 1.07 +/- 0.12 after 3 and 6 months, respectively.Combined vascular therapy may be used effectively in patients with chronic extremity ischemia owing to multiple levels of arterial occlusion and should be performed with good results. Technical success and early patency rates are excellent. The patients' symptoms improved and resistant ischemic ulcers healed within a short period of time.