الفهرس 
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Abstract
The aim of this study was to evaluate the clinical and hemodynamic outcome of chronic lower limb ischemia treated by hybrid revascularization procedures. It was an interventional study that included 86 patients having peripheral arterial disease category 2 to 6, according to Rutherford classification (109) and multi level occlusive disease. Patients fulfilling the inclusion criteria were provided with information sheets and asked to give written informed consent after explaining to them the steps, risks and benefits of the procedures. Patients with extensive foot necrosis necessitating amputation or major renal dysfunction (Creatinine >2.4mg/dl) (105) were excluded from the study.
After taking history, examining the legs and performing the routine laboratory tests, patients were investigated using color duplex ultrasound (CDU), multisclice computed tomography angiography (MSCTA), magnetic resonance angiography (MRA) or direct arteriography. Hybrid revascularization procedures, combining both open surgical and endovascular procedures have been done to all cases tailored according to the lesion pattern. All procedures were performed by vascular surgeons in an operating room. The most common type of open surgical procedure done was femoral artery endarterectomy. Most of them were done by the conventional technique for endarterectomy. As regards the endovascular part of the intervention, most patients had it done at the same setting with the open surgical procedure. Only 2 patients had the endovascular procedure done before the surgical part at a separate occasion. All procedures were done under totally aseptic conditions mostly under regional or general anesthesia. All patients except 2, had femoral artery as the site for vascular access, the other 2 patients had brachial artery approach. Patients were followed up for 1 year with clinical examination and ABI measurement after 2 weeks, 6 months and 1 year of the procedure. Color duplex ultrasound was after 6 months of the procedure.
Eighty-six patients who presented with chronic peripheral arterial disease were included in the study. They were 60 males (70%) and 26 females (30%). The mean age (+SD) was 71.4±8.8 years. Forty percent of patients were diabetics, 57% were hypertensive and 78% were either smokers or ex-smokers. Although 86 patients were included in the study, the follow-up results were analyzed for 77 patients, because at one year follow-up 6 had died and 3 lost follow-up. None of the mortalities were related to the interventions. Fifty two patients (60%) were having intermittent claudication and 34 (40%) had critical limb ischemia. For those who presented with claudication, the claudication distance ranged from 10 to 200 meters with a median of 50 meters. Seventy three percent of patients had unilateral lower limb ischemia. Ten patients had a previous vascular intervention in the same limb being treated in the study, all of which were endovascular revascularization, except one had an occluded arterial bypass. Forty percent of patients had a pre-operative CDU done. All 86 patients had a pre-operative angiography done, out of which CIA, EIA and CFA disease were shown in 69%, 71% and 93% respevtively. All scans were MSCTA except 4 patients had MRA and 1 patient had direct arteriography.
The distribution of distal runoff according to the number of patent tibial vessels were as follows 14% of patients had one vessel, 33% had 2 vessels and 53% had 3 vessels runoff. All patients had unilateral interventions. 98% of the study population had the hybrid revascularization procedures done simultaneously, while only 2% had the procedures at two different occasions.
As regards the open surgical part of the procedure, 77 patients had common femoral artery endarterectomy (FEA). As regards the endovascular part of the intervention, 68 patients (79%) had inflow procedures, 16 (19%) had outflow procedures and only 2 (2%) had angioplasty for both inflow and outflow tracts. Sixty one patients (71%) had stents deployed whether primarily or secondarily. The remaining 25 patients (29%) had only balloon angioplasty. As regards the open revascularization, technical success was 100%. However, technical success was 95% (82 patients) for the endovascular section of the procedure. In 4 cases (5%) the guide wire did not cross the lesion and this was considered an immediate anatomical failure of the endovascular section of the procedure.
Mean follow-up period was 14.1+2 months. The mean ABI (+SD) before and 1 year after intervention were 0.5 (+0.2) and 0.7 (+0.2) respectively (mean change 0.2), this was clinically and statistically significant. As for those patients who had claudication, the median claudication distance (+SD) increased from 50 meters before intervention to 75 meters after 2 weeks of intervention. This was clinically and statistically significant. At 6 months interval, 75 patients had CDU and at one year interval all patients were clinically examined for peripheral pulses and any new symptoms documented. Primary patency rates for open surgical intervention was 97%. Primary patency rates for inflow and outflow endovascular procedures were 88% and 76% respectively. Among the patients with claudication 77% had no complaint of IC, 13% still had claudication, 4% had gone re-interventions and 6% were awaiting further re-intervention.
Patients who presented with CLI were assessed after one year. 86% had limb salvage, 10% had a major amputation and 3% had re-intervention vascular procedure. The only patient who needed a re-intervention has had FEA and iliac balloon angioplasty. He presented with worsening symptoms and after ensuring patency of the previously treated segments he had a femoro-peroneal bypass. The only two risk factors which had a statistically significant impact on the fate of limb after one year of intervention were diabetes and hypertension, with a p-value of 0.036 and 0.028 respectively.
Ninety one percent of patients did not experience any complications. 5 patients had post-operative groin hematomas, they were all drained surgically. One patient had post-operative acute thrombosis of the Ilio-Femoral arterial segment after doing FEA and iliac balloon angioplasty. This was managed with successful open surgical thrombectomy, re-do patch closure and iliac stenting.