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Vol 15, No 1 (2009)
Research paper
Published online: 2009-02-24

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Hybrid surgery - new possibilities for surgical treatment of chronic lower extremity ischaemia in patients in poor general condition. One year of observation

Mieczysław Grodowski, Rafał Boczej, Ryszard Walas, Krzysztof Pietrzak, Marek Motyka
Acta Angiologica 2009;15(1):20-29.


Background. The aim of this paper was the assessment of the effectiveness of concurrent endovascular angioplasty with stenting and classic "open" surgery in patients in poor general condition with numerous cardiovascular and respiratory risk factors, during one year of observation.
Material and methods. The study group consisted of 43 persons (68.2% men and 31.8% women, with an average age of 63.7 years), selected from 56 patients operated on in our clinic in 2007, in which simultaneous surgery with use of "C" arm was carried out. All operations were performed in elective mode. During initial evaluation of all patients, the ankle-brachial pressure index (ABPI) was measured and - for assessment of intermittent claudication distance — walking test was performed with a runway velocity 3.4 km/h, if possible (patients with resting pains were excluded). All patients were qualified for surgery by a cardiologist; their average EF was 41.3%. The frequency of co-morbidities in this group was: ischaemic heart disease 58%, previous myocardial infarction 16%, previous CABG or PTCA 12%, diabetes 33%, chronic kidney disease 7%, cerebral vascular diseases 47%, arrhythmia 14%, and hypertension 67%. According to these co-morbidities, patients were qualified by an anaesthesiologist to ASA groups as follows: ASA I - 5%, ASA II - 43%, ASA II/III - 16%, ASA III - 30%, and ASA IV - 9%. The patients were operated on under local anaesthesia. In all of them endovascular angioplasty with or without stenting of the iliac artery was done and then, after improving arterial low, the classic operation was performed - outflow angioplasty of common femoral and deep femoral artery or femoropopliteal bypass, as needed. If there was not satisfactory arterial flow to the ischaemic extremity, and concurrent stenosis of br>opposite iliac artery was present, endovascular dilation of this artery ("flow donor") was performed and next non-anatomical suprapubic crossover femorofemoral bypass was carried out. The average duration of a single operation was 1 h 48 min.
Results. Of the 43 operations performed, in 1 case (2.3%) it was necessary to make an intraoperative change to the classic technique; an iliofemoral bypass was carried out in the first case because of a breakage of the external iliac artery during balloon angioplasty. In 2 cases (3.5%) scheduled amputation was performed, at shin level in 1 case (1.7%) and at forefoot level in 1 case (1.7%). All patients were discharged in good general condition and with considerable improvement of perfusion in the operated leg, with a recommendation of taking oral antiplatelet and hypolipaemic medications. During postoperative follow up in 43 patients, ankle-brachial pressure index (ABPI) was measured and walking test on a running track was performed. The average objective preoperative distance of claudication was 49.09 m, and during the postoperative year it increased to an average of 358.38 m; in patients with critical ischaemia the resting and nocturnal pain has withdrawn, and the distance of claudication has increased to an average of 120 m. The average value of ABPI in the whole group before surgery was 0.315, and at the end of first postoperative year it has increased to 0.87.
Conclusions. Early results of the study show the great effectiveness of hybrid surgery, especially in patients with numerous co-morbidities limiting the possibilities of "open" revascularisation. In one year of observation, it has been shown that the obtained postoperative improvement of blood supply in the operated extremity is maintained at a constant satisfactory level, and that the clinical effect of this treatment was good.

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