Balloon angioplasty and stent placement during operative vascular reconstruction for lower extremity ischemia

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.

The Role of Hybrid Procedures in the Management of Peripheral Vascular Disease

This paper provides a summary of up-to-date information and experience with the combined treatment of patients suffering from peripheral arterial disease (PAD) with endovascular and open surgery, performed simultaneously and in a single operating room. Hybrid intervention is reported to have good results in well-indicated groups of patients with acute and chronic limb ischemia, even with older, high-risk patients. The indications for the use of this technique remain unclear with inconsistent opinions among vascular surgeons. The indications for treatment were divided into three main groups: 1) Patients with chronic limb ischemia, 2) acute limb ischemia, and 3) occlusion of a previous vascular reconstruction. The operating techniques for the most commonly used combinations are described.

In conclusion, hybrid operating techniques are often useful when treating complex problems and multilevel disease in patients with chronic or acute lower limb ischemia. Modern vascular surgeons need to master both open and endovascular techniques, and to combine them in a creative fashion to the benefit of our patients.

Iliac angioplasty and stenting in association with infrainguinal bypasses: timing and techniques

Inflow iliac artery balloon angioplasty may be performed simultaneously with open infrainguinal vascular reconstruction in patients with multilevel occlusive disease of the lower extremity. This approach is safe, effective, has satisfactory long-term results, and should be part of the vascular armamentarium.

Intraoperative superficial femoral artery balloon angioplasty and popliteal to distal bypass graft: an option for combined open and endovascular treatment of diabetic gangrene

PURPOSE

The purpose of this study was to evaluate the results of combining intraoperative balloon angioplasty (IBA) of the superficial femoral artery (SFA) with distal bypass graft originating from the popliteal artery as a method of lower extremity revascularization in diabetic patients with gangrene.

METHODS

Among 380 infrainguinal bypass grafts performed over a 6-year period, there were 110 reversed saphenous vein bypass grafts to the tibial or pedal arteries to treat diabetic patients with gangrene. Diffuse infrainguinal disease was treated with femoral-distal bypass graft (long; n = 46). Popliteal-distal bypass graft was performed when the inflow femoral artery was not significantly diseased (short; n = 52). Focal SFA stenosis and severe infrageniculate disease were treated with combined IBA of the SFA and distal bypass graft originating from the popliteal artery (combined; n = 12). Follow-up was performed with duplex scan surveillance of both the bypass graft and IBA sites. Treatment groups were compared with life-table analysis.

RESULTS

There were no perioperative graft failures or amputations. The perioperative mortality rate was 1% (1 of 110). The 2-year primary patency rates were similar in the three groups: 72% in the long bypass graft group, 82% in the short bypass graft group, and 76% in the combined group (P =.8, log-rank test). SFA IBA sites developed recurrent stenosis in two patients, at 7 and 48 months; both were detected with surveillance and treated with percutaneous transluminal balloon angioplasty. The overall 5-year rate of primary patency was 63%, secondary patency was 78%, limb salvage was 81%, and survival was 35%. There were no significant differences among the three treatment groups with respect to these outcomes.

CONCLUSION

Results with the combined procedure were similar to those achieved with either femoral-distal bypass graft or popliteal-distal bypass graft without SFA IBA. These data suggest that IBA of the inflow SFA may be combined with popliteal to distal bypass graft and that this technique is a reasonable alternative to longer, femoral-origin bypass graft in selected diabetic patients with gangrene.

Should balloon angioplasty and stents have any role in operative intervention for lower extremity ischemia?

Balloon angioplasty has been combined with open vascular surgery to treat lower extremity ischemia due to multilevel occlusive disease. The purposes of this study were: (1) to compare staged and simultaneous approaches to determine the optimal method for combining endovascular and open techniques and; (2) to assess the role of stents in intraoperative balloon angioplasty. Among 274 patients undergoing lower extremity revascularization over 30 months, 38 (13.9%) required a combination of endovascular and open techniques; 17 were staged (endovascular followed at an interval by distal open surgery) and 21 were simultaneous (intraoperative balloon angioplasty with or without stent placement at the time of open surgery). Groups were similar with respect to demographics, lesions treated with endovascular intervention, incidence and location of stent placement, and results of surgery. Additional operating time required for intraoperative endovascular intervention was 41.0 +/- 30.7 min., fluoroscopic time was 3.9 +/- 2.4 min. and contrast administered was 58.8 +/- 28.1 ml. There was no perioperative mortality. Length of stay was longer in the staged than in the simultaneous group (p < 0.01). Cumulative combined primary patency at 1 year by life-table methods was 82 +/- 10% in the staged group and 83 +/- 9% in the simultaneous group (p = 0.79). Mean follow-up was 13 +/- 6 months. There is a role for balloon angioplasty and stent placement in operative revascularization of ischemic limbs in selected patients: patency was similar to that produced with the staged approach while the length of stay was shorter. Intraoperative balloon angioplasty is safe and effective and stents permit a measure of control in assuring an optimal intraoperative postangioplasty result.