Chief, Vascular Surgery Maimonides Health Brooklyn, New York
Objectives: Complex femoropopliteal artery occlusive disease (CFPOD) involving multilevel femoral and popliteal lesions is traditionally managed with femoral-to–below-knee popliteal bypass (BKB). Although autologous vein provides superior durability, availability of suitable conduit is frequently limited, and prosthetic BKB is associated with inferior patency. We evaluated a hybrid femoral-to–above-knee popliteal bypass (HYB), combining open bypass with endovascular popliteal revascularization, as an alternative strategy for CFPOD.
Methods: Patients with complex femoropopliteal artery occlusive disease and chronic limb-threatening ischemia or lifestyle-limiting claudication who underwent hybrid femoropopliteal bypass (HYB) between 2019 and 2024 were prospectively registered. Indications for HYB included absence of suitable autologous vein and/or high surgical risk for prolonged open revascularization. Patients undergoing conventional femoral-to–above-knee (AKB) or femoral-to–below-knee popliteal bypass (BKB) between 2013 and 2024 served as retrospective controls. The hybrid technique combined open femoral-to–above-knee bypass with endovascular popliteal revascularization using balloon angioplasty and covered stent placement. Primary endpoints were primary and secondary patency; secondary endpoints included major adverse limb events, operative time, length of stay, discharge disposition, and perioperative morbidity and mortality. Patency was assessed by Kaplan–Meier analysis and compared using the log-rank test.
Results: A total of 147 bypasses were analyzed, including 34 HYB, 44 AKB, and 69 BKB procedures. Median follow-up was 24 months. Baseline demographics and comorbidities were similar among groups. HYB patients more frequently had prior ipsilateral endovascular intervention, and disease severity was greater in the HYB and BKB groups, reflected by higher runoff scores compared with AKB (11.4 and 11.5 vs 5.7; P < .01). Estimated primary patency at 12 and 24 months was 87.4% and 76.4% for HYB, 78.5% and 63.8% for AKB, and 67.6% and 59.1% for BKB (overall log-rank P = .167). Secondary patency at 24 months was highest in the HYB group (84.9%) compared with AKB (63.8%) and BKB (62.9%; P = .095). HYB was associated with significantly shorter operative time, shorter hospital stays, fewer discharges to rehabilitation facilities, and fewer MALEs compared with BKB, without increased perioperative morbidity or mortality. In subgroup analysis, 12-month primary patency was significantly higher for HYB than for BKB, including BKB performed with vein conduit.
Conclusions: Hybrid femoral-to–above-knee popliteal bypass is a safe and effective revascularization strategy for CFPOD, achieving durable patency comparable to AKB and superior to BKB while reducing operative complexity. HYB represents an important option for patients lacking suitable autologous vein or at high risk for prolonged open surgery.
