Distal hybrids - an option in long SFA CTO accompanied by severely compromized crural runoff P. Kuryanov, A. Lipin, A. Antropov, K. Atmadzas, A. Atmadzas, Y. Eminov, A. Borisov, R. Sobolev, A.Orlov
Limb Salvage Center, St.-Petersburg - Large volume hospital for pts with soft tissue infections - 160 hospital beds for CLI patients - Vascular/endovascular surgery unit arranged in 2014 - Over 450 PVI yearly, ~100% CLI - 80% endo, 15% open, 5% hybrid
Disclosure Speaker name: PAVEL KURYANOV I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest
Distribution and symmetry of arteriosclerotic lesions of the lower extremities: an arteriographic study of 200 limbs Waldren R. et al., 1985 63% SFA lesions
Distribution of arteriosclerotic lesions of the lower extremities: Limb Salvage Center, St.-Petersburg, 600 patients 100% Rutherford 5-6 SFA lesions - 69% SFA CTO > 20 cm 37.7% Of these: 3-vessel crural CTO 37% Peronea as the sole runoff vessel 16%
Conventional strategies SFA PTA ± stent + Crural PTA Long tibial bypass
What speaks in favor of endo? Sachs T. et al., 2011 (~560 000 cases done between 1997-2007): 3-fold increase in the number of CLI cases treated in endovascular fashion 40% decrease in the number of open intereventions
What speaks in favor of endo? Swedvasc registry data 2008 2009 2010 2011 2012 2013 Open 40% 37% 35% 32% 33.5% 29% Endo 60% 59% 61% 64% 62.5% 67%
What speaks in favor of endo? BASIL trial Bradbury A. et al., 2010 5y amputation-free survival: NS
What speaks in favor of endo? Antoniou G. et al., 2013 Meta-analysis of 2817 cases (CLI 80-100%) Endo Open 30-day mortality rate 3% 3%, NS 1-y amputation-free survival 71% 76%, NS 1-y primary patency 62% 72% (significant)
What speaks in favor of endo? Studies showing impressive long-term outcome of PTA±stent in long SFA CTO Author, year N CLI% Mean lesion length Palena L., 2017 Hong S., 2013 Lichtenberg M., 2013 Lagana D., 2011 Stent Technical success 30d mortality 1y primary patency 1y AFS 34 100% 27.9 см 100% 100% 0% 94,1% 82,4% 161 33% 22.6 см 100% 94% 0% 77% - 22 100% 24.5 см 100% 100% 0% 77% - 52 100% - 100% 100% 0% 76,9% -
What speaks in favor of endo? Romiti M. et al., 2008 Meta-analysis of crural PTA studies (2653 cases, 30 studies, 1990 2006) Technical success - 89% 30-day mortality rate 1.8%
What speaks in favor of endo? Popplewell M.A. et al., 2017 (n=104) Randomized comparison of РТА vs tibial bypass (BASIL trial)
What speaks in favor of endo? IIB VASCUNET report (2012): 32084 cases, 9 countries
What speaks in favor of endo? Bisdas T. et al., 2016 CRITISCH registry, 129 patients treated with tibial bypass 30-d bypass failure 19.4% 30-d major amputation 4.7%
What speaks in favor of open? TASC II (2007) Open surgery is a method of choice in TASC D lesions AHA/ACC Guideline on Management of Patients with LE-PAD (2016) Open surgery is the method of choice in multi-level disease ESC guidelines (2017) Bypass with vein a method of choice in SFA lesions >25 cm
What speaks in favor of open? VASCUNET report (2012): 32084 IIB cases, 9 countries
What speaks in favor of open? SVS/Vascular Quality Initiative (2016)* * ~1/3 of all interventions done for SFA disease are open, and mostly for long lesions
What speaks in favor of open? Pomposelli F. et al., 2003 >1000 bypassess to a. dorsalis pedis, 10-year follow-up Early mortality - 0.97% Early failure 4.2% AMI 3.0%
What speaks in favor of open? Shah D. et al., 1995 2058 patients treated with in situ bypass, 10-y follow up
What speaks in favor of open? BASIL trial Bradbury A. et al., 2010 5-y AFS NS! SFA lesions only in 80% TASC D only in ~1/4
What speaks in favor of open? Lofberg A. et al., 2001 SFA lesion type and the long-term patency Short stenotic lesion Long stenotic lesion SFA CTO
What speaks in favor of open? Ah Chong A. et al., 2009: type of SFA lesion (TASC II) and the long-term patency after SFA PTA TASC A TASC B TASC C TASC D
What speaks in favor of open? Davies M. et al, 2008: crural runoff and the long-term patency after SFA PTA
The concept of distal hybrid Open part Endo part Vein bypass to a. poplitea Outflow reconstruction with crural PTA Higher patency vs PTA Shorter bypass less likelihood of restenosis BTK amputation doesn t require bypass ligation Direct angiosomic revascularization Late reocclusion doesn t cause CLI (bypass still functioning)
Is it safe to perform a vein bypass to an isolated popliteal segment? Author, year n Bypass Distal anastomosis Early failure rate Brochado NF, 2000 11 Vein a. genu descendens, a. suralis medialis, Isolated popliteal artery 9% 2 y 73% Davis RC, 1975 55 Vein Isolated popliteal artery - 4 y 70% Primary patency Satiani B, 1986 25 Vein/ PTFE Isolated popliteal artery 0% 3 y 84.1% 3 y (PTFE) 41.7% Loh A, 1993 33 Vein Isolated popliteal artery - 3 y 76% Brewster DC, 1984 de Latour B, 2008 de Luccia N, 2011 Barral X, 1998 22 Vein/ PTFE Kram HB, 1991 217 Vein/ PTFE Vein Isolated popliteal artery - 5 y - 71% 51 Vein a. genu descendens, a. suralis medialis 47 Vein a. genu descendens, a. suralis medialis a. genu superior, a. suralis medialis 3,3% 3 y 65% 0% 3 y 74,7% - 1 y 77% Isolated popliteal artery - 5 y 74% 5 y 55% (PTFE)
Is it safe to perform a vein bypass to an isolated popliteal segment? 2 weeks 3 months 2 years 2 years 10 years
Is it safe to perform a vein bypass to an isolated popliteal segment? AHA/ACC Guideline on Management of Patients with LE-PAD, 2016 In addition, composite sequential femoropopliteal-tibial bypass and bypass to an isolated popliteal arterial segment that has collateral out flow to the foot are both acceptable methods of revascularization and should be considered when no other form of bypass with adequate autogenous conduit is possible (326,327).
Distal hybrids in Limb Salvage Center, St.-Petersburg 33 pts CLI 100% (all Rutherford 5-6) Females, n (%) 8 (24.2%) Age, y (mean, range) 69.5 (45-88) CAD, n (%) 17 (51.5%) Diabetes, n (%) 12 (36.4%)
Lesion distribution on angio IIB with vein 100% SFA CTO >20 cm Proximal PA always patent 5 pts (15.2%) had distal PA CTO Crural PTA 3-vessel CTO in 26 (78.8%) Peronea as the only outflow vessel in 7 (21.2%)
Staging and endo access Staged* N=14 (42.4%) Simultaneous N=19 (52.6%) Step 1 vein bypass Step 2 Crural PTA through crossover femoral access Side branch access N=16 (84.2%) Crossover femoral access N=3 (15.8%) * 2-14 day interval
Crural angioplasty* 1-vessel PTA 66.6% (n=22) 2-vessel PTA 30.4% (n=10) 3-vessel PTA 3% (n=1) Angiosomic revascularization 91% (n=30) * PTA of distal popliteal segment was done in 4 pts; Stent implanted in 3 (9%) pts.
AC and AP strategy NFH 60 IU/kg intraoperatively (both for open and endo steps) No AC postoperatively Simultaneous hybrids done on ASA, clopidogrel initiated postoperatively For staged hybrids: open step done on ASA, clopidogrel administered prior to crural PTA
30-d complications 1 (3%) death due to MI 2 (6%) cases of early graft failure (both after simultaneous hybrids) 1 (3%) crural artery reocclusion (bypass functioning, ulcer healed) 1 (3%) major amputation
Long-term outcome 2 years: - AFS (n=24) - 75% - Bypass primary patency (n=12) 58% - Crural PTA patency (n=12) 0% - PA patency (n=3) 66%
Case 1: simultaneous distal hybrid
Case 1: simultaneous distal hybrid
Case 1: 1.5 year outcome
Case 2: staged distal hybrid
Case 2: staged distal hybrid
Conclusions 1. Distal hybrids are a viable option in long SFA CTO accompanied by crural disaster 2. Despite outflow reocclusion in the long run you may still have high AFS due to a functioning bypass 3. Need larger comparative studies 4. Need flow-meter to compare volume flow vs tibial bypass.