Multilevel lesions of lower extremities arteries: choosing the optimal surgical approach

INTRODUCTION. One of the important problems in cardiovascular surgery is the multilevel lesions of the lower extremity arteries. We presented the results of treatment of multilevel arterial lesion.

METHODS AND MATERIALS. We analyzed the treatment results of 90 patients with combined lesions of the aortofemoral and femoral-popliteal segment of type TASC C and D. The patients were divided into 2 groups and 2 subgroups. Group 1 consisted of patients who underwent combined multilevel interventions, in turn, group 1 was divided into 2 subgroups according to the type of interventions. Group 1A – closed remote endarterectomy (RE) from the iliac arteries + femoral-popliteal (tibial) bypass surgery. Group 1B – aorto (iliac) – femoral bypass + RE from the arteries of the femoral-popliteal segment. Group 2 consisted of patients who underwent combined aorto (iliac) femoral + femoral-popliteal (tibial) bypass surgery.

RESULTS. There were no registered cases of shunt thrombosis in the early postoperative period in group 1, whereas in group 2, both aorto-femoral and femoral-popliteal shunt thrombosis occurred in three cases (12%) in the early postoperative period. In group 1, 1 episode of bleeding was registered that required revision, in group 2, no bleeding was registered. In groups 1 and 2, 1 case of myocardial infarction (MI) was registered in the early postoperative period (p=0.301), one patient in group 2 had a stroke with regression of symptoms in the postoperative period. There were no deaths or amputations in the early postoperative period in group 1. In group 2, two patients (8%) underwent amputation in the early postoperative period, one patient died in the postoperative period. The primary patency in group 1A by 12, 24 and 60 months was 95 %, 76 % and 63 % respectively, in group 1B by 12, 24 and 60 months was 86 %, 86 % and 81 %, respectively, in group 2 by 12, 24 and 60 months was 100 %, 100 % and 85 %, respectively (p=0.368). Secondary patency in group 1A by 12 months was 77 %, by 24 months was 77 % and by 60 months was 52 %. In group 1B – by 12 months – 100 %, by 24 months – 67 %. In group 2 – by 12 months and 24 months – 50 % (p =0.983).

CONCLUSIONS. Thus, if it is impossible to perform hybrid procedures, combined interventions for multi-level lesions of lower extremity arteries is an acceptable alternative to multi-level bypass. There was no difference in long-term patency between the compared methods of interventions, but the presence of fatal complications in the group of multilevel bypass indicates the advantage of a less invasive approach.

1. Ricco J. B., Thanh Phong L., Belmonte R. et al. Open surgery for chronic limb ischemia: a review. J. Cardiovasc. Surg. (Torino). 2013;54:719–727.

2. Demographic Yearbook of Russia. 2019: Stat.sb./ D 31. Rosstat. M., 2019:252. (In Russ.).

3. Takayama T., Matsumura J. S. Complete lower extremity revascularization via a hybrid procedure for patients with critical limb ischemia. Vasc Endovascular Surg. 2018;52(4):255–261. https://doi.org/10.1177/1538574418761723.

4. Kireev K. A., Fokin A. A., Rodnianskiĭ D. V. Hybrid intervention for an atherosclerotic lesion of arteries of the iliofemoral segment. Angiol. Sosud. Khir. 2018;24:156–159.

5. Troitskiĭ A. V., Bekhtev A. G., Khabazov R. I. et al. Outcomes of hybrid operations in multi storeyed lesions of arteries of the aortoiliac and femoropopliteal segments. Angiol. Sosud. Khir. 2013;19:39–44.

6. Puzdriak P. D., Shlomin V. V., Shloĭdo E. A. et al. Hybrid surgical treatment of a multilevel lesion of lower-limb arteries. Angiol. Sosud. Khir. 2018;24:80–89.

7. Brothers T. E., Greenfield L. J. Long-term results of aortoiliac reconstruction. J. Vasc. Interv. Radiol. 1990;1:49–55.

8. Royster T. S., Lynn R., Mulcare R. J. Combined aortoiliac and femoropopliteal occlusive disease. Surg. Gynecol. Obstet. 1976;143:949–952.

9. Nypaver T. J., Ellenby M. I., Mendoza O. et al. A comparison of operative approaches and parameters predictive of success in multilevel arterial occlusive disease. J. Am. Coll. Surg. 1994;179:449–456.

10. Benson J. R., Whelen T. J., Cohen A., Spencer F. C. Combined Aortoiliac and Femoropopliteal Occlusive Disease : Limitations of Total Aortofemoropopliteal Bypass. Annals of surgery. 1965;163(1):121–130.

11. Tanaka A., Sandhu H. K., Perlick A. et al. Superficial femoral artery occlusion reduces aortofemoral bypass graft patency. Eur. J. Vasc. Endovasc. Surg. 2019;57:650–657.

12. Madiba T. E., Mars M., Robbs J. V. Aortobifemoral bypass in the presence of superficial femoral artery occlusion: does the profunda femoris artery provide adequate runoff? J. R. Coll. Surg. Edinb. 1998;43:310–313.

13. Sharples A., Kay M., Sykes T. et al. Multilevel bypass grafting : Is it worth it ? Ann. Vasc. Surg. 2014;28(7):1697–1702. https://doi.org/10.1016/j.avsg.2014.03.027.

14. Edwards W. H., Wright R. S. A technique for combined aorto-femoralpopliteal arterial reconstruction. Ann. Surg. 1974;179:572–579.

15. Collins G. J. J., Rich N. M., Andersen C. A., McDonald P. T. Staged aortofemoropopliteal revascularization. Arch. Surg. 1978;113: 149–152.

16. Martinez B. D., Hertzer N. R., Beven E. G. Influence of distal arterial occlusive disease on prognosis following aortobifemoral bypass. Surgery. 1980;88:795–805.

17. DeBakey M. E. The development of vascular surgery. Am. J. Surg. 1979;137:697–738.

18. Ebaugh J. L., Gagnon D., Owens C. D. et al. Comparison of costs of staged versus simultaneous lower extremity arterial hybrid procedures. Am. J. Surg. 2008;196:634–640.

19. Dosluoglu H. H., Lall P., Cherr G. S. et al. Role of simple and complex hybrid revascularization procedures for symptomatic lower extremity occlusive disease. J. Vasc. Surg. 2010;51:1425–1435.e1.

20. Mukhamadeev I. S., Oborin A. A., Danilov V. N., Vronskiĭ A. S. Results of loop endarterectomy and femoropopliteal bypass grafting in TASC C and D lesions. Angiol. Sosud. Khir. 2021;27:107–112. (In Russ.).

21. Gisbertz S. S., Tutein Nolthenius R. P., de Borst G. J. et al. Remote endarterectomy versus supragenicular bypass surgery for long occlusions of the superficial femoral artery: medium-term results of a randomized controlled trial (the REVAS trial). Ann. Vasc. Surg. 2010;24:1015–1023.

22. Sumner D. S., Strandness D. E. Aortoiliac reconstruction in patients with combined iliac and superficial femoral arterial occlusion. Surgery. 1978;84:348–355.

23. Brewster D. C., Perler B. A., Robison J. G., Darling R. C. Aortofemoral graft for multilevel occlusive disease. Predictors of success and need for distal bypass. Arch. Surg. 1982;117:1593–1600.

24. Samson R. H., Scher L. A., Veith F. J. Combined segment arterial disease. Surgery. 1985;97:385–396.