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Combined Surgical and Endovascular Approaches

Juan Carlos Parodi, MD; Luis Mariano Ferreira, MD

Department of Vascular Surgery of the Instituto Cardiovascular de Buenos Aires,
Ciudad Autónoma de Buenos Aires, Argentina

   The possibility of combining two types of approaches in the peripheral vascular field is a less aggressive alternative and with results that are comparable to the conventional treatment (1-6). In our operating room, (acting as vascular surgeons having intra-operative fluoroscopy images with high resolution?), we have the possibility to alternate or to combine both approaches according to the patient's clinical and anatomical characteristics. These techniques, however, can be carried out in simultaneous or sequential fashion Carotid or infrarenal vessels are territories in which such combination helps obtain better results, patient's better and quicker recovery, especially those high risk populations in which a surgery like an obstruction of the intra-thoracic common carotid artery is associated to a high morbidity and mortality rate.

   With reference to combined procedures, an enumeration of the same ones would allow to group them according to the pathology and territory in aneurysmatic or obstructive disease and among this last group in carotid vessels, or those corresponding to the infrarenal aorta and its branches.

   From September of 1990, when we performed in our institution the first procedure for the endovascular exclusion of an aneurysm, a series of combined approaches has been carried out, among which we can mention:
1) Temporary conduit for the introduction of the endovascular device, by means of the suture of an end of a tubular Dacron graft to the common iliac artery, in cases of stenosis or small size of the iliac or femoral arteries.
2) We performed a crossover by-pass (femoro-femoral) to establish the contralateral flow in the case of the exclusion of an aneurysm by an aorto-uni-iliac endograft.
3) Combined treatment of the aortic aneurysm (endoluminal) and other associated aneurysms (hypogastric or femoral arteries).
4) Treatment of hypogastric aneurysm or iliac pseudoaneurysm primarily by an endoluminal fashion with coils to diminish bleeding and then by conventional approach.
5) Ligation (in the cases of not being able to carry it out endoluminally) or relocation (in the cases of bilateral or accidental occlusions) of the hypogastric artery in patients with aneurysms of the common iliac artery before the deployment of an aortic endograft.
6) Repair of iatrogenic lesions of the aorta, iliac, femoral, or subclavian artery, etc.
7) Ligation of the lumbar arteries or the inferior mesenteric artery (type II endoleak) either by retroperitoneal or video-assisted approach
8) Banding of the proximal and distal necks after the endoluminal exclusion of the aneurysm.
9) Thrombectomy followed by angioplasty of an occluded iliac limb.

   The by-pass or the endarterectomy like conventional procedures for the treatment of the lower limbs occlusive disease can be combined with other endovascular procedures. The simultaneous treatment is already universally used for the multi-segmental pathology; either proximal or distal to the segment to be treated conventionally (7-9)

   The infrainguinal by-pass completes a fundamental role for lower extremity revascularization, especially to prevent the limb amputation in diabetic patients with critical ischemia. The limb salvage in these patients with gangrene depends on the restitution of blood flow to the distal level. (Fig 1) This generally implies the confection of a distal vein bypass with a primary patency rate of 70% at 5 years and limb salvage non higher than 80%. This group of patients is characterized to present a short life-expectancy, associated to a great quantity of comorbidities, apart from usually presenting multi-segment arterial stenosis. The ideal treatment in these patients is to perform the shortest and simple by pass that offers an appropriate perfusion to the extremity. The presence of a lesion either proximal or distal to the segment to be replaced, available to be treated endoluminally, shortens the longitude of the bypass. A poor run-off, usually seen in these patients, forces to use a vein. On the other hand, the saphenous vein is not always available for distal reconstruction because of earlier harvesting for coronary bypass grafting, lower extremity revascularization, inadequate vein size, previous phlebitis, removal for varicosities or structural defects within the vein. The below-knee angioplasty would allow to choose the best vein segment, or to make an above-knee distal anastomosis, even to avoid a previously exposed or infected area. Once the place to which the by-pass will be discharged is established, it is important to obtain a correct in-flow, which is subscripted in most of the cases to the femoral territory.

Fig.1: a)Pre and b)postoperative arteriogram of dorsalis pedial angioplasty in a patient in which a simultaneous femoro popliteal bypass was performed.

   In some other cases the absence of disease in the femoral territory, enables us on the contrary, to use the superficial femoral artery or inclusive the popliteal artery like an adequate in flow. This is exactly the group of patients to which we will refer in this chapter. Those in which the problem is in the proximal inflow , with short lesions which can benefit from the combination of both approaches (Fig 2).

Fig.2: a)Preoperative angiogram showing a severe common and deep femoral artery stenosis b) Femoro-peroneal bypass

   Although a proximal angioplasty, either in iliac or femoral artery, is not generally enough in diabetic patients with critical ischemia, the combination of a by-pass assures a better distal perfusion. The combined procedure shortens the surgical times, and allows to perform the procedure under epidural anesthesia. It shortens the vein segment to be used diminishing the quantity of incisions. The fact of being able to use a short segment of vein favors these patients with a high incidence of contralateral occlusive disease (25% requires revascularization of the other limb in the first 5 years), coronary disease, or the necessity of a graft for dialysis.

   Recently there has been interest in the use of isolated limb perfusion in patients with a severe and live-threatening limb ischemia with oxygenated blood, thrombolitic agents, PGE1 and free radicals scavengers. Cannulas are placed in the common femoral artery and common femoral vein, with a pneumatic tourniquet that assures the superficial vein blockade. This procedure has carried out in unstable patients with a severe ischemia of an entire limb, in which the release of substances related to the reperfusion would be highly noxious (ADRS, renal insufficiency, cardiac failure, etc)

   The incorporation of the endovascular technique has become a routine procedure. This is also given in the carotid territory where the occlusive disease of the common carotid artery could be treated by means of a combined technique. (10) Their proximal lesions are a relative contraindication for the endovascular treatment, since the cerebral protection from distal embolization is a technically difficult point to achieve. In the cases of distal occlusions close to the carotid bifurcation, by the time of placing the proximal end of the carotid shunt, we connect it to a catheter placed percutaneously coming from the brachial artery. In this way the blood flow settles down from the brachial artery inflow through a catheter toward the distal internal carotid artery. Thus, we can avoid to cross the stenotic segment of the common carotid artery with a shunt, and potentially embolize (Fig 3). Thus, the approach of the stenotic segment of the distal common carotid artery is then conventionally treated by means of endarterectomy. However, if the lesion is in the ostium or in the intra-thoracic position, this approach allows us to treat it safely and endoluminally, either in a retrograde or antegrade fashion. In these cases, the brachial to internal carotid shunt protects the cerebral perfusion, while the particles are easily washed by means of the common carotid artery declamping.

Fig.3: Brachial to internal carotid artery temporary shunt

   The combined approach also allows us to have an access to the common carotid artery under local anesthesia. This represents the option to carry out an angioplasty in the cases in which canulation of the common carotid artery can not be achieved (aorto-iliac occlusion or severe tortuosity of the aortic arch).

   The combined endoluminal and conventional approach is feasible and at the same time a less aggressive technical alternative, having demonstrated in the short and medium term to possess a similar permeability to the exclusively conventional approach.

REFERENCES

1. May J, White GH. Combined Surgical and endovascular approaches. En White R, Fogarty TJ, editors: Peripheral endovascular interventions. St. Louis Missouri. 1996;433-448. Mosby - Year Book Inc.

2. Simultaneous or stepwise procedure in combined minimal invasive and conventional operation methods in vascular surgery]. Langenbecks Arch Chir Suppl Kongressbd 1998;115:1295-8.

3. Ruckert RI, Romaniuk P, Rogalla P, Thieme T, Umscheid T, Stelter WJ, Muller JM. Combined surgical and endovascular removal of thrombus entirely occluding a bifurcated aortic stent-graft. J Endovasc Surg 1998 Nov;5(4):323-8.

4. Wellman BJ, Loftus CM, Noh D, Barnhart WH, Howard MA 3rd A combined surgical-endovascular device concept for giant aneurysm neck occlusion. Neurosurgery 1998 Jun;42(6):1364-8; discussion 1368-9.

5. Todd GJ, DeRose JJ, Martin EC. Complementary surgical/interventional techniques for nonresective management of "inoperable" aneurysms: a second look. Ann Vasc Surg 1998 May;12(3):248-54.

6. Meyer T, Merkel S, Lang W. Combined operative and endovascular treatment of a post-traumatic embolizing aneurysm of the subclavian artery. J Endovasc Surg 1998 Feb;5(1):52-5.

7. Hamilton IN Jr, Mathews JA, Sailors DM, Woody JD, Burns RP. Combination endovascular and open treatment of peripheral arterial occlusive disease performed by surgeons. Am Surg 1998 Jun;64(6):581-90; discussion 590-2.

8. Marin ML, Veith FJ, Sanchez LA, Cynamon J, Suggs WD, Schwartz ML, Parsons RE, Bakal CW, Lyon RT. Endovascular aortoiliac grafts in combination with standard infrainguinal arterial bypasses in the management of limb-threatening ischemia: preliminary report. J Vasc Surg 1995 Sep;22(3):316-24; discussion 324-5.

9. Schneider PA, Caps MT, Ogawa DY, Hayman ES. Intraoperative superficial femoral artery balloon angioplasty and popliteal to distal bypass graft: an option for combined open and endovascular treatment of diabetic gangrene. J Vasc Surg 2001 May;33(5):955-62.

10. Arko FR, Buckley CJ, Lee SD, Manning LG, Patterson DE. Combined carotid endarterectomy with transluminal angioplasty and primary stenting of the supra-aortic vessels. J Cardiovasc Surg (Torino) 2000 Oct;41(5):737-42.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
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