Stent Plus Popliteal Distal Bypass for Limb Salvage

Journal Pre-proof Simultaneous SFA angioplasty/stent plus popliteal distal bypass for limb salvage David Barillà, MD, Domenico Spinelli, MD, Francesco Stilo, MD, Graziana Derone, MD, Narayana Pipitò, MD, Francesco Spinelli, MD, Filippo Benedetto, PhD, MD PII:

S0890-5096(19)30862-3

DOI:

https://doi.org/10.1016/j.avsg.2019.10.032

Reference:

AVSG 4680

To appear in:

Annals of Vascular Surgery

Received Date: 7 April 2016 Revised Date:

6 October 2019

Accepted Date: 8 October 2019

Please cite this article as: Barillà D, Spinelli D, Stilo F, Derone G, Pipitò N, Spinelli F, Benedetto F, Simultaneous SFA angioplasty/stent plus popliteal distal bypass for limb salvage, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2019.10.032. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.

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Simultaneous SFA angioplasty/stent plus popliteal distal bypass for limb salvage David Barillà, MD, Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy. Domenico Spinelli, MD, Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy. Francesco Stilo, MD, Vascular Surgery, University of Campus Biomedico of Rome, Italy. Graziana Derone, MD, Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy. Narayana Pipitò, MD, Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy. Francesco Spinelli, MD, Vascular Surgery, University of Campus Biomedico of Rome, Italy. Filippo Benedetto, PhD, MD, Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy..

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Abstract

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Background: Treatment of severe critical limb ischemia (CLI) due to Superficial Femoral Artery (SFA) and below-the-knee (BTK) vessels’ involvement could be compromised by the lack of a Great Saphenous Vein (GSV) suitable in its entire length. The purpose of this study is to assess the efficacy of a hybrid endovascular and open lower limbs arterial reconstruction in these patients with multilevel, advanced CLI.

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Methods: From 2005 to 2019, we performed hybrid endovascular and surgical treatment for limb salvage in SFA-BTK CLI. This consisted of percutaneous transluminal angioplasty (PTA) with or without stenting of the SFA, along with distal origin vein graft bypass. Inclusion criteria were: Rutherford category 5 or 6, lack of a suitable GSV, patency of the popliteal artery, steno-obstructive lesions of the SFA, lesions of the three crural vessels > 5 cm in length each. The follow-up was performed with duplex scan surveillance of both the bypass graft and PTA sites.

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Results: The hybrid treatment could be performed in 34 patients. 56% of the SFA steno-obstructive lesions were treated with simple PTA, except for the application of a bare metal stent in one patient (3%), while in all the SFA occlusions PTA was completed with covered stents (41%). Thirty-four popliteal-to-distal vein bypass grafts bypass grafts have been performed. There were no perioperative PTA or bypass graft failures. Clinical improvement was achieved in 26 (76%) patients. Overall, primary and secondary patency, limb salvage, and survival rates were 65%, 68%, 75%, and 75% at 5 yrs, respectively.

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Conclusions: A hybrid strategy in multilevel SFA-BTK CLI is a well established approach. Additional studies are warranted to validate these results.

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Introduction

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In these recent years, there have been notable, continuing advances in imaging, endovascular equipment and techniques that allow percutaneous transluminal angioplasty (PTA), with or without stenting, as a primary revascularization procedure for critical limb ischemia (CLI)1,2. However, surgical femoro-distal bypass grafting, using in situ or reversed autogenous vein, remains the gold standard for lower limb salvage in multisegment superficial femoral artery (SFA) and below-the-knee (BTK) TASC D CLI3-6. In fact, while endovascular procedures guarantee excellent long-term patency of the SFA (1 year primary and secondary actuarial patency rates 74% and 84% respectively)7,8, the results in the BTK level, especially for TASC D lesions, are far from being satisfying9. Some authors report 1-year primary patency of 53%, 58%, 67%, and 37% for TASC A through D lesions, respectively10.

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The Great Saphenous Vein (GVS) has been shown to be the best conduit for infrapopliteal arterial bypass grafts. Nevertheless, up to 20% of patients undergoing lower limb revascularization do not have an adequate amount of autologous veins, as a result of previous peripheral or coronary artery bypass procedures, previous vein stripping for varicose veins, or inadequate size or quality. Moreover, prosthetic grafts to infrapopliteal arteries yield poor long-term patency rates, although long-term anticoagulation therapy may improve these results11.

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PTA and surgery are clearly complementary therapies. Therefore, each one must be individualized by teams who are not vested in one therapy or another. TASC II classification, comorbidities, vein conduit availability, and life expectancy should all be considered to tailor patients’ individual therapy12.

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In this setting of concomitant SFA-BTK CLI, and in the lack of a suitable length GSV, a hybrid procedure could be indicated. PTA of the SFA (with or without stenting) allows a shorter popliteal- todistal bypass graft to be performed, so improving the outcomes associated with this kind of bypass grafts12-14.

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In our study we combined two different techniques, each one largely validated for different level of intervention (endovascular for SFA, surgical for BTK), and we aimed to assess the efficacy of such an hybrid arterial reconstruction in patients with multilevel CLI in the lack of suitable autologous vein.

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Materials and Methods

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A single centre study was conducted including all patients undergoing a hybrid treatment for CLI (endovascular treatment of the SFA, along with distal vein by-pass graft originating from a downstream artery), between January 2005 and April 2019. We retrospectively analysed a prospectively collected database, based on the clinical, operative and outpatient reports.

68 69 70

A team of vascular surgeons with expertise in endovascular procedures selected the patients deemed suitable for hybrid lower limb arterial reconstruction. The indications for this type of hybrid interventions were based on the following criteria: Rutherford category 5 or 6, as defined by the

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Society for Vascular Surgery/International Society for Cardiovascular Surgery, North American Chapter reporting standards17, the lack of a suitable GSV (<3 mm in diameter) along its whole length, the patency of the popliteal artery, steno-obstructive lesions of SFA, lesions of the three crural vessels > 5 cm in length each. All patients were preoperatively evaluated by duplex-ultrasound (DUS). Contralateral GVS has never been used because vascular patients have a multi-district atherosclerotic disease therefore they could need autogenous vein for major cardiovascular or contralateral lower limb revascularization.

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From 2005 we performed 64 hybrid procedures of revascularizations but we analysed 34 patients because data of thirty patients were uncompleted.

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Patients with concomitant SFA-BTK TASC C or D lesions and a suitable GSV underwent long femoro-crural by-pass graft originating from the common femoral artery (CFA) or proximal SFA. Patients with an unsuitable GSV and SFA-BTK TASC C or D lesions underwent long femoro-crural composite bypass graft with complementary distal arteriovenous fistula and deep vein interposition for infrapopliteal anastomosis (Ascer AVF). All these patients were excluded from the current series. Patients with TASC A or B lesions of SFA and crural vessels underwent sole endovascular treatment and were also excluded from the current series.

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SFA stenoses were considered significant when caused loss of triphasic flow distally to the lesion, at DUS, or more than 50% lumen reduction at angiography, and were treated primarily with PTA alone. SFA occlusions were treated with endoluminal or sub-intimal recanalization and PTA. A bare metal or covered self-expanding stent was used at discretion of the surgeon, if flow limiting dissection or recoil was observed at the completion angiography.

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The endovascular and bypass procedures were performed simultaneously. All procedure was carried out in a dedicated surgical room with a mobile fluoroscopic C-arm (Philips BV Pulsera, Philips Medical Systems, Amsterdam, The Netherlands and EuroColumbus AlienE 3030 Cardio, Milano, Italy).

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All procedures were performed by the same team of vascular surgeons with expertise in endovascular procedures from the ipsilateral CFA access. An antegrade approach was undertaken in all procedures thanks to the patent and the absence of CFA illness. An antegrade CFA access was always chosen because it does not modify the result.

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Depending on the availability of autologous veins, the residual ipsilateral GSV was selected as a first choice (27 patients), followed by the small saphenous vein (SSV, 6 patients) or a vein of the upper limb (1 patient). All of the veins were translocated and, according to the calliper congruence they were devalvulated or inverted. The site of the proximal anastomoses was chosen among distal SFA, supragenicular and infragenicular popliteal artery (PA) depending on the presence of triphasic flow and absence of angiographic lesions proximally. The outflow vessel was chosen based on the presence of in-line flow to the foot.

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According to the surgical needs and to the candidates’ risk profile, patients underwent epidural, spinal or local anaesthesia, or nerve blockages. Intra-operative heparin was administered intravenously at the dose of 100 IU kg-1. Digital subtraction angiography of the plantar arch and intraoperative continuous wave Doppler, or DUS, distally to the distal anastomosis, have been performed at the end of both the endovascular and surgical procedures.

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All patients underwent tissue lesion' surgical debridement, or minor amputations, during the same surgical session, or shortly thereafter. All patients were discharged with dual anti-platelet therapy for the first post procedural three months, then just with ASA as life-time treatment. Follow-up included duplex-ultrasound control at 1, 3, 6, 12 months, and annually thereafter, as well as ambulatory wound care until the healing of the lesions.

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Technical success of SFA PTA was defined as a residual stenosis of <30% at completion arteriography. Technical success for the distal by-pass grafts was defined as an improvement of blood-flow to the target vessel at the perimalleolar site, distal to the site of anastomosis, or even at the interdigital level, after unclamping of the graft, as revealed by intraoperative continuous wave Doppler, or DUS .

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Clinical improvement was defined according to the reporting standards15, as an upward shift by at least two Rutherford categories.

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Statistics

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Statistical analysis was performed with IBM SPSS Statistics 20.0 (IBM Co., Armonk, NY, USA). Demographic data and risk factors were analysed with the chi-square test. Primary, assisted, and secondary patency, limb salvage, and survival were estimated with the Kaplan-Meier life table method.

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Results

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During the study period, 34 patients (29 men, 5 women) underwent a hybrid endovascular and surgical treatment: PTA with or without stenting of the SFA along with distal origin vein graft by- pass (Fig. 1). In all cases, the procedures were planned simultaneously. The mean age was 74,04 yrs. (range: 59 to 83 yrs). Patients had a history of smoking (70,6%), Hypertension (79,4%), Diabetes (76,5%), Chronic Renal Failure (44,1%), Coronary Artery Disease (38,23%) with previously coronary revascularization (14,7%), Chronic Obstructive Pulmonary Disease (53%), Dyslipidaemia (50%), Cerebrovascular Disease (14,7%). No patient was lost at follow-up (mean: 50.04 mo). Table 1 reports the risk profile of the study group. The clinical category was Rutherford 5 and 6 in 18 and 16 patients, respectively.

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An antegrade endovascular procedure was always performed through the CFA to treat SFA stenosis (20 cases) or occlusion (14 cases). Nineteen lesions have been treated with simple PTA standard dilation for 1-3 minutes (Passeo-18, Biotronik AG, Buelach, Switzerland), 14 with covered stents (Viabahn, WL Gore, Flagstaff, Arizona, mean length 7.8 cm, range: 5-15; BeGraft, Bentley, Hechingen, Germany; Tigris Vascular Stent, WL Gore & Associates UK Ltd, Livingston, UK), and 1 with a Zilver PTX nitinol stent (Cook Medical, Bloomington, Indiana). All of the 14 occlusions were treated with

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self-expanding covered stent, while a nitinol stent was used as bailout for a post-PTA flow limiting dissection.

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The proximal anastomosis of the bypass grafts has been performed from the supragenicular PA in 11 patients, and from the infragenicular in 23. The outflow vessel was the anterior tibial artery in 19 patients (56%), the posterior tibial in 6 (17,64%), the pedidial in 5 (15%), the plantar and the peroneal both in 2 (5,9%). The GSV was used in 27 patients (79,4%, 6 inverted); the SSV in 6 (17,6%, 2 inverted); the cephalic vein in 1 (3%). Technical success was always achieved.

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Clinical improvement was achieved in 26 (76%) patients. Angiosome revascularization was not always possible because of the advanced stage of TASC classification and therefore the lack of angiosomespecific arteries.

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All patients underwent a lifestyle intervention to modify cardiovascular risk factors, such as tobacco use, physical activity, hypertension, dyslipidaemia and metabolic risk factors.

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Six patients presented with acute occlusion of the by-pass during follow-up. Three patients underwent hybrid management: bypass embolectomy and anterior tibial artery PTA, distally to distal anastomosis; one patient underwent open surgical re-intervention and the target vessel was changed from retromalleolar posterior tibial artery to peroneal artery. Two patients underwent amputation due to a runoff disease progression and the typical “desert foot” at the angiography.

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Not all patients achieved adequate control of cardiovascular risk factors and someone else did not continue the antiplatelet therapy. Due to these factors and the runoff disease progression they underwent to amputation.

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Overall, primary patency was 85%, 82%, 77%, and 65% at 30 days, 12, 36, and 60 mo, respectively; secondary patency: 85% and 63% at 24 and 60 mo, respectively; limb salvage: 81%, 81% and 68% at 24, 36 and 60 mo, respectively; survival rates: 96%, 96%, 96%, 91%, and 76% at 6, 12, 24, 48, and 60 mo, respectively. (Fig. 2 and 3)

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Discussion

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Successful revascularization and limb salvage, in patients affected by multilevel CLI, traditionally required lengthy, often staged, interventions with significant associated morbidity and mortality. When a tibial or pedal bypass graft is required, it may originate from the CFA; if the femoral inflow vessels are free of disease, a PA origin bypass graft is a reasonable option3,16.

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In our series we present a subset of patients who would be candidates for bypass grafts originating from the CFA because of the presence of focal SFA stenosis or occlusion. However, in the presence of a GSV inadequate in its length or quality, we preferred to combine endovascular and open techniques by performing intraoperative PTA of the focal SFA stenosis, with or without stenting, and a distal bypass graft originating from the PA.

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Even if PTA and surgery are likely to be complementary, with different indications12, patency rates are much lower after infrapopliteal angioplasty compared with bypass surgery17.

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In 2001, Schneider et al. published the first report in the literature, describing the endovascular treatment of the SFA to enable placement of a distal origin bypass graft12. They reported their results in 12 patients who underwent intraoperative PTA of focal TASC A SFA lesions PA-to-distal bypass grafts. They found no differences in patency or limb salvage when compared with their experience with either CFA-to-distal, or PA-to-distal bypass grafts without SFA PTA.

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The annual number of hybrid procedures is increasing. Aho and Venermo18 reported that, in their experience, this number ranged between 4 in 2004 and 73 in 2011. Among these hybrid procedures in different districts, the proportion of endovascular cases performed by vascular surgeons increased from 0% in 2004 to 86.3% in 2011.

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In the current series, all the 7 occlusions were treated with the Viabahn self-expanding covered stent. The Viabahn stent graft has been used extensively for the treatment of femoropopliteal occlusive disease, and there are numerous publications of single and multicenter experiences with this device19,20. A single-centre randomized trial compared the results of the Viabahn-covered stent versus above-theknee femoropopliteal bypass surgery with prosthetic graft material for long-segment femoropopliteal occlusive disease21. Four-year follow-up shows no differences between the 2 treatment strategies, with regard to primary or secondary patency. We think that the expanded polytetrafluoroethylene (ePTFE) can be used like a femoropopliteal “endobypass”, and the graft material lining the stent serves as a barrier to neointimal in-growth, thereby reducing the risk of in-stent restenosis.

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The advantages of a distally based inflow procedure stay in the fact that it requires less vein conduit, gives the surgeon the opportunity to perform the procedure with the best segment of the conduit itself, avoids groin dissections in obese patients, and thigh dissection in patients with venous stasis or oedema. In our series the origin of bypasses, was the supragenicular popliteal artery in 11 cases and the infragenicular popliteal artery in 23 cases.

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Autogenous vein bypass graft is the gold standard treatment for Rutherford stage 5 and 6 CLI, associated with stenosis and/or extended arterial thrombosis (TASC C or D)22,23. Multiple reports established primary vein graft patency rates up to 80% and 60% at 1 and 5 years24,25, respectively, with 5-year limb salvage rates exceeding 80% in patients presenting with non-healing ulcers or rest pain26,27. In the current series, overall primary patency was 85%, 82%, 77%, and 65% at 1, 12, 36, and 60 mo, respectively; overall limb salvage was 81%, 81%, and 60% at 24, 36, and 60 mo, respectively.

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The best results can be expected when saphenous veins are used as conduits. Even alternative vein conduits, most of which were arm vein grafts in this study, are preferable because they perform far better in the BTK district than the expected performance of prosthetic grafts28. In fact, the use of less than optimal “high-risk” conduit has been shown to produce inferior amputation-free survival29. Also a varicose GSV as an alternative conduit for femoro-distal bypass grafts has been previously described30.

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In the present series, GSV, SSV, or arm vein were used as arterial conduits in all the patients. Technical success was achieved in all patients, and clinical improvement in more than 70%.

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Factors negatively affecting the patency of such interventions include the quality of the run off vessels, the severity of CLI and the length of the diseased segments22,23. In all cases of our series, the distal bypass graft was planned simultaneously to the endovascular procedure in order to provide an adequate run-off to the covered stent graft in the SFA. Performing hybrid surgery may also greatly reduce hospital charges and the length of stay (LOS). Ebaugh et al evaluated the costs of staged versus simultaneous lower limb arterial hybrid procedures. Notably, the unadjusted results showed that hospital charges and LOS were more than doubled if staged rather than simultaneous hybrid procedures were performed31.

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Conclusion

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Our report confirms the efficacy of a hybrid strategy in high-risk surgical candidates, as it relates to morbidity, mortality, and limb salvage. Percutaneous SFA intervention, followed by distal origin grafts placement for multilevel CLI, is a feasible, durable and effective revascularization strategy. The use of PTFE covered stent, as an “endobypass” for SFA treatment seems to have similar results of PTFE bypass graft, but providing less invasivity. Limitations of the present study include the small number of patients from a single centre, and their heterogeneity, which makes them not directly comparable. Therefore, additional studies are needed to address the best therapeutic approaches to further optimize long-term outcomes.

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Fig. 1 Preoperative and postoperative angiography

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Fig. 2 Limb salvage and survival rates

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Fig. 3 Primary and secondary patency rate

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References

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1. Nasr MK, McCarthy RJ, Hardman J, et al. The increasing role of percutaneous transluminal angioplasty in the primary management of critical limb ischaemia. Eur J Vasc Endovasc Surg 2002;23:398-403.

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2. Molloy KJ, Nasim A , London NJ, et al. Percutaneous transluminal angioplasty in the treatment of critical limb ischemia. J Endovasc Ther 2003;10:298-303.

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3. Pomposelli FB, Marcaccio EJ, Gibbons GW, et al. Dorsalis pedis artery bypass: durable limb salvage for foot ischemia in patients with diabetes mellitus. J Vasc Surg 1995; 21:375-84.

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4. Spinelli F, Pipitò N, Martelli E, et al. Endo first is not appropriate in some patients with critical limb ischemia because "bridges are burned". Ann Vasc Surg 2014 Nov 26. [Epub ahead of print] PubMed PMID: 25433285.

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5. Schneider JR, Walsh DB, McDaniel MD, et al. Pedal bypass versus tibial bypass with autogenous vein: a comparison of outcomes and hemodynamic results. J Vasc Surg 1993;17:1029-38.

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6. Rutherford RB, Jones DN, Bergentz SE, et al. Factors affecting the patency of infrainguinal bypass. J Vasc Surg 1988;8:236-46.

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7. Alimi YS, Hakam Z, Hartung O, et al. Efficacy of Viabahn in the treatment of severe superficial femoral artery lesions: which factors influence long-term patency? Eur J Vasc Endovasc Surg. 2008;35:346–352.

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8. Surowiec SM, Davies MG, Eberly SW, et al. Percutaneous angioplasty and stenting of the superficial femoral artery. J Vasc Surg. 2005 Feb;41(2):269-78.

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9. Lo RC, Darling J, Bensley RP, et al. Outcomes following infrapopliteal angioplasty for critical limb ischemia. J Vasc Surg. 2013 Jun;57(6):1455-63; discussion 1463-4. doi: 10.1016/j.jvs. 2012.10.109. Epub 2013 Feb 1.

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10. Giles KA, Pomposelli FB, Spence TL, et al. Infrapopliteal angioplasty for critical limb ischemia: Relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs, J Vasc Surg. 2008 Jul;48(1):128-36. doi: 10.1016/j.jvs.2008.02.027. Epub 2008 May 23.

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11. Veith FJ, Gupta SK, Ascer E, et al. Six-year prospective multicentre randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc Surg 1986;3:104-14.

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12. Schamp KB, Meerwaldt R, Reijnen MM, et al. The Ongoing Battle Between Infrapopliteal Angioplasty and Bypass Surgery for Critical Limb Ischemia. Ann Vasc Surg 2012; 26: 1145–1153.

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13. Schneider PA, Caps MT, Ogawa DY, et al. 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;33(5): 955-62.

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14. Lantis J, Jensen M, Benvenisty A, et al. Outcomes of combined superficial femoral endovascular revascularization and popliteal to distal bypass for patients with tissue loss. Ann Vasc Surg 2008;22(3):366-71.

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15. Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997;26(3),517-38.

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16. Brothers TE, Robinson JG, Elliot BM, et al. Is infrapopliteal bypass compromised by distal origin of the proximal anastomosis? Ann Vasc Surg 1995;9:172-8.

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17. Romiti M, Albers M, Brochado-Neto FC, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008;47:975-81.

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18.Aho PS and Venermo M: Hybrid procedures as a novel technique in the treatment of critical limb ischemia. Scand J Surg 2012;101:107-13.

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19. Lammer J, Dake MD, Bleyn J, et al. Peripheral arterial obstruction: prospective study of treatment with a transluminally placed selfexpanding stent-graft. International Trial Study Group. Radiology 2000;217:95–104.

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20. Saxon RR, Coffman JM, Gooding JM, et al. Long-term patency and clinical outcome of the Viabahn stent-graft for femoropopliteal

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21. McQuade K, Gable D, Pearl G, Theune B, Black S. Four-year randomized prospective comparison of percutaneous ePTFE/nitinol self-expanding stent graft versus prosthetic femoral- popliteal bypass in the treatment of superficial femoral artery occlusive disease. J VascSurg 2010;52:584–90; discussion 590–1, 591.e1–e7.

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22. Norgren L, Hiatt WR, Dormandy JA; et al. TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg 2007 33, S1eS75.

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23. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45:S5-S67.

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24. Shah DM, Darling RCIII, Chang BB, et al. Long-term results of in situ saphenous vein bypass. Analysis of 2058 cases. Ann Surg 1995;222:438-46.

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25. Pomposelli FB, Kansal N, Hamdan AD, et al. A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases. J Vasc Surg 2003;37:307-15.

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26. Nasr MK, McCarthy RJ, Budd JS, et al. Infrainguinal bypass graft patency and limb salvage rates in critical limb ischemia: influence of the mode of presentation. Ann Vasc Surg 2003;17:192- 7.

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27. Faries PL, Logerfo FW, Arora S, et al. A comparative study of alternative conduits for lower extremity revascularization: allautogenous conduit versus prosthetic grafts. J Vasc Surg 2000;32:1080-90.

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28. Veith FJ, Gupta SK, Ascer E, et al. Six-year prospective multicentre randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc Surg 1986;3:104-14.

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31. Ebaugh JL, Gagnon D, Owens CD, et al: Comparison of costs of staged versus simultaneous lower extremity arterial hybrid procedures. Am J Surg 2008;196: 634-40.

Demography Age

74,04

Smoking

24 (70,6%)

Hypertension

27 (79,4%)

Chronic Renal Failure

15 (44,1%)

Coronary Artery Disease

13 (38,23%)

PTCA-Stenting-CABG

5 (14,7%)

Chronic Obstructive Disease

18 (53%)

Dyslipidemia

17 (50%)

Cerebral Vascular Disease

5 (14,7%)