Treatment Outcomes of Femorodistal Bypass and Hybrid Procedure for Femoropopliteal and Infrapopliteal Lesions in Patients with Chronic Limb-Threatening Ischemia

ABSTRACTObjective This study aimed to compare clinical outcomes between bypass surgery and hybrid therapy in patients with chronic limb-threatening ischemia (CLTI) who had combined femoropopliteal (FP) and infrapopliteal (IP) lesions. Methods This multicenter retrospective study included patients with CLTI who underwent bypass surgery (BSX group) or hybrid therapy, which involved combining endovascular therapy for FP lesions with popliteal to distal bypass (Hybrid group), between 2015 and 2022. Amputation-free survival (AFS), limb salvage (LS), overall survival (OS), and wound healing were compared between the two treatment strategies. Results This study included 125 patients (BSX, n=77; Hybrid, n=48). End-stage renal disease was more common in the Hybrid group than in the BSX group (50% vs 30%, P=0.036). Global Limb Anatomic Staging System (GLASS) FP grade 4 was more prevalent in the BSX group than in the Hybrid group (86% vs. 65%, PP=0.28). Multivariate analysis showed that a high Wound, Ischemia, and foot Infection (WIfI) stage was a significant risk factor for poor AFS (hazard ratio, 1.75; 95% confidence interval, 1.13 - 2.90; P=0.018). The 2-year LS rate in the BSX and Hybrid groups was 92% and 92%, respectively (P=0.95). OS at 2 years was 75% and 62% in the BSX and Hybrid groups, respectively (P=0.24). Wound healing rates at 2 years were comparable between the two groups (BSX group: 69% vs. Hybrid group: 64%, P=0.40). Conclusions In patients with CLTI who had combined FP grade 3-4 and IP lesions, hybrid therapy demonstrated acceptable clinical outcomes regarding AFS, LS and wound healing, despite a higher prevalence of FP grade 4 lesions in the bypass surgery group. Hybrid therapy may be considered a viable alternative to bypass surgery for patients with CLTI and combined FP and IP lesions. However, these findings should be interpreted with caution, considering the presence of selection bias and the poor primary patency rate of the grafts in the hybrid group.