Hybrid revascularization of complex multilevel disease: a paradigm shift in critical limb ischemia treatment.

Critical limb ischemia frequently occurs on a background of extensive co-morbidities and carries a poor prognosis which requires urgent management. Disease severity and patient comorbidity influence the initial choice of management which according to traditional paradigms, is a choice between open or endovascular repair. Over the last decade hybrid intervention, which is the planned combined use of both open and endovascular techniques, has increasingly been used to tackle multilevel disease. In this review we look at the techniques and results of hybrid surgery. This technique is ideal for multilevel lesions, as it is minimally invasive, allows prompt limb revascularization as opposed to the delays inherent in staged procedures and it appears to be more convenient to patients. It also leads to reduced length of hospital stay and reduces overall cost. Most importantly it offers an alternative to open revascularization in medically high risk patients. The success and popularity of hybrid interventions has been underpinned by advances in stent and balloon technology and the advent of the hybrid operating theatre which has allowed multiple techniques to be used simultaneously. Iliac angioplasty and stenting is now the first line of treatment for TASC C/D iliac lesions with good technical success and long-term patency. In patients who also have common femoral disease, endarterectomy can be combined with iliac stenting and this has now almost replaced open bypass. Most series for a variety of hybrid procedures report good limb salvage rates, with morbidity and mortality data considered equal to or better than open bypass procedures. Careful patient selection and detailed preoperative planning are essential to achieve these excellent results. Studies have reported on prospective series or retrospective analysis for various hybrid techniques, including non randomized trials comparing hybrid and open surgical treatment. Ideally, a randomized controlled trial comparing open and hybrid treatment is needed to minimize confounding variables.