[Abstract] Objective To investigate the clinical efficacy of hybridization technique in the treatment of occlusive lesions of the common femoral artery involving the external iliac artery. Methods A retrospective analysis of the clinical data of 47 patients with occlusive lesions of the common femoral artery involving the external iliac artery admitted from May 2008 to April 2013 was performed. All patients underwent femoral artery endarterectomy and iliac artery balloon dilation and stenting, and the perioperative results and arterial recanalization were observed. Results All patients completed the procedure successfully. The average number of stents implanted per patient was (1.51±0.75), and the postoperative ankle-brachial index (ABI) increased by 0.54 compared with that before surgery. The perioperative complication rate was 17.0%; (8/47), with no deaths. The mean follow-up time was (673.6±384.4) days. Four patients developed in-stent occlusion at follow-up. Using Kaplan-Meier survival analysis, the first-stage patency rate was (97.8±2.2%) at 12 months and (86.3±6.7%) at 24 months after surgery. Conclusion The perioperative results and early follow-up of the hybridization technique for occlusive lesions of the common femoral artery involving the external iliac artery are favorable. In recent years, with the rapid development of endoluminal techniques, most iliac artery and femoral artery lesions can be resolved by endoluminal techniques. In common femoral artery stenosis and occlusive lesions, traditional endarterectomy has good results [1]. However, in some patients, the lesions of the common femoral artery involve the external iliac artery, and simple endarterectomy cannot resolve the iliac artery lesions located above the inguinal ligament, although complete endoluminal techniques have recently been reported for trans-acetabular lesions [2-4], but data on long-term patency rates are lacking. We treated 47 cases of occlusive and stenotic lesions of the common femoral artery involving the external iliac artery using hybridization techniques, with good results, as reported below. From May 2008 to April 2013, 47 patients with atherosclerotic occlusive disease involving the common femoral artery and external iliac artery underwent femoral artery endarterectomy and iliac artery balloon dilation and stenting. Forty-one of them were men and 6 were women; their ages ranged from 43 to 81 years, with a mean age of (65.5±8.73) years. There were 25 cases of left iliofemoral metastases and 22 cases of right iliofemoral metastases, among which 7 patients also had stenotic lesions of the contralateral iliac artery. The average length of the lesions was 8.52 years. The mean lesion length (8.52±3.31) cm. preoperative ankle-brachial index (ABI) was 0.39±0.12 (0-0.7). Comorbid diseases: coronary heart disease in 32 cases, hypertension in 33 cases, diabetes mellitus in 10 cases, hyperlipidemia in 16 cases, cerebral infarction in 12 cases, renal insufficiency in 3 cases, and chronic obstructive pulmonary disease in 3 cases. Of the 47 patients, 28 were treated with general anesthesia and 19 were treated with local anesthesia plus intravenous reinforced anesthesia. After the upper limb brachial artery puncture or contralateral femoral artery puncture, the common femoral artery lesion involving the external iliac artery was confirmed by imaging, a longitudinal inguinal incision was made from the anterior superior iliac spine to the midpoint of the pubic symphysis on the affected side, the common femoral artery, the superficial femoral artery and the deep femoral artery were freed, the inguinal ligament was pulled upward, the proximal common femoral artery and the external iliac artery were freed as much as possible, and they were banded and controlled separately. After heparinization, the common femoral artery was dissected longitudinally, and local endothelial debris and floating endothelial fragments were thoroughly cleared, and the distal endothelial fragments were properly fixed. The proximal guidewire is passed through the diseased segment of the iliac artery with a catheter, and the caudal end is led out of the femoral artery incision to the superficial femoral artery, where the femoral artery incision is enlarged by direct suturing or patching, starting with a proximal suture and then blocking the femoral artery incision. The stent is placed above the inguinal ligament and completely covers the external iliac artery, and then the femoral artery incision is closed. Postoperative pharmacological treatment: for those who have been treated with clopidogrel and aspirin before surgery, continue to give dual anti-treatment after surgery; for those who have not been given dual anti-treatment before surgery, give pumped heparin therapy (maintaining activated clotting time (ACT) at 200s-300s) or low molecular heparin subcutaneously (0.1 ml/kg once every 12 hours) after surgery, depending on the outflow tract. After 3 days, the anticoagulant therapy was discontinued and the dual antiplatelet therapy was continued, and after 1 year of postoperative dual anti-treatment, the treatment was changed to aspirin alone. 1.3 Follow-up methods The follow-up included general condition, clinical symptoms such as claudication, Doppler ultrasound and flowmetry to check arterial patency and ABI. 1.4 Statistical methods SPSS13.0 statistical software was used. All measures were expressed as mean x – ± s standard deviation, and the patency rate was calculated by KaplanMeier method. 2. Results 2.1. Perioperative results All patients completed the surgery successfully. The operative time was (112±37.4) minutes, the intraoperative bleeding was (276.3±197.8) ml, and 4 patients received 4 U of suspended red blood cells intraoperatively, while the rest did not receive blood transfusion. The average number of stents implanted per patient was (1.51±0.75), and 7 patients underwent simultaneous stenting of the contralateral iliac artery. The stents included Smart control (Cordis, USA), Complete SE (Medtronic, USA), Maris (Intec, Italy), and Fluency (Bard, USA) stents. In one patient, the femoral artery was reinforced with an autologous saphenous vein patch. The postoperative ABI was 0.93±1.89 (0.47-1.23), with a mean increase of 0.54 compared with the preoperative period, and all patients showed significant improvement in lower limb ischemia. The incidence of postoperative complications was 17.0%; (8/47), and there was no death in the whole group. The perioperative complications included acute thrombosis of the iliofemoral artery in one case, which was caused by floating residual endothelial fragments on repeat transbrachial angiography, and stenting was performed after thrombolysis and the patient was discharged successfully. Two patients had wound liquefaction, which healed well after dressing change treatment. The average follow-up time was (673.6±384.4) days (the follow-up rate of this group was 100%; those who were not followed up were not included in the group). Three patients were reopened with endoluminal treatment, and one patient improved with conservative medication. The Kaplan-Meier survival rate analysis showed a first-stage patency rate of (97.8±2.2%) 12 months after surgery and (86.3±6.7%) 24 months after surgery. There are several solutions for occlusive lesions of the common femoral artery involving the external iliac artery. The traditional iliac-femoral artery bypass and aortofemoral artery bypass have good long-term results, but they require an open or extraperitoneal approach and are more invasive. Recently, treatment has been performed exclusively with endoluminal techniques, but stenting is required across the hip joint, and some reports have shown acceptable near-term patency rates, but data on long-term patency rates are lacking. Bonvini et al [6] performed endoluminal treatment in 360 patients with sclerotic occlusions of the common femoral artery, of which 133 were dilated and stented, while the rest were treated with balloon dilation alone. The 1-year restenosis (>50%) rate was 27.6% and the reintervention rate was 19.9%. Simó et al [7] treated 155 patients with these lesions using a hybrid technique, i.e., femoral artery endarterectomy with iliac artery stenting, and the follow-up results showed that the rates of first-stage patency, first-stage secondary patency, and second-stage patency at years 1, 3, and 5 were 80.2%; 74.7%; and 69.7%, respectively. 74.7%; and 69.3%; 84.8%; 82.4%; and 78.2%; 86.8%; 84.2%; and 79.6%; respectively, indicating the good results of hybridization in the treatment of these lesions. There are other reports of using hybridization techniques for these lesions with good results [8, 9]. In our group of 47 patients, all of whom had external iliac and common femoral artery lesions across the hip joint, we chose to treat them with the hybridization technique when the long-term effect of the transarticular stent was uncertain, and the perioperative results and follow-up results showed good results. There are some technical details that need to be taken into account during the procedure: first, the choice of access to the iliac artery lumen. We chose to open the occluded segment of the external iliac artery by puncturing through the upper limb artery or the contralateral femoral artery, rather than opening the external iliac artery after endarterectomy of the affected femoral artery. If we choose to open the external iliac artery retrogradely, the guidewire will easily enter the subintima and form a clot, and forcible opening will easily damage the normal segment of the iliac artery or even form a clot in the abdominal aorta. If we open the iliac artery from the upper limb artery or the femoral artery on the opposite side, we can open it in the direction of blood flow, starting from the exact proximal lumen, which has a high success rate and is less likely to enter the subendothelium and form a sandwich. After successful opening of the occluded segment, the guidewire is delivered into the distal superficial femoral artery and then endothelial stripping of the femoral artery is performed, and the proximal and distal ends of the guidewire are located in the true lumen, ensuring the safety of endoluminal treatment. In addition, the distal end of the iliac artery stent needs to be located within the denuded artery and therefore needs to be precisely positioned, either too low to enter below the inguinal ligament or too high to completely cover the lesioned segment. Release of the stent from the upper limb artery or the contralateral femoral artery allows precise control of the stent head for positioning, which is more certain than retrograde release for control of the stent tail. After completion of femoral artery endothelial debridement, a portion of the proximal incision is sutured before releasing the stent. In both direct suturing and patching, the sutures are started at the proximal femoral artery, and the proximal femoral artery is blocked for approximately 1/2 of the full length to release the iliac artery stent, and the entire femoral artery incision is sutured after the stent is released. If the external iliac artery stent is released first, the proximal femoral artery cannot be blocked due to the presence of the stent, and forcible clamping may result in stent damage. If a patch is applied, the end of the stent should be located at the beginning of the patch rather than at the weak point of the proximal endothelial debridement, which may cause damage to the vessel wall or even rupture due to the expansion force of the stent. In one case, the end of the stent was not placed in the patch, but at the proximal end of the patch, at the end of the external iliac artery. Because of the severe calcification of the iliofemoral artery and the weakness of the vessel wall after endothelial debridement, the end of the stent was found to have punctured the vessel wall after implantation, and a small amount of blood leaked. After stenting, the end of the stent was found to have punctured the vessel wall and there was a small amount of blood leakage. With advances in endoluminal technology and improved devices, transarticular lesions are no longer off-limits for endoluminal treatment. Newer stents such as the Supera (IEV Technologies, Inc., USA) stent have better flexibility and fracture resistance than traditional stents, and can withstand prolonged bending with less stent fracture and can be used for transarticular lesions. Recent studies have shown good near-term results, but there is a lack of data on long-term results in a large number of cases. The present study shows that the use of a small incision in the inguinal region to manage common femoral artery lesions involving the external iliac artery using a hybridization technique has a low incidence of serious perioperative complications and is effective, with significant improvement in lower extremity ischemia in all patients. The results of our follow-up show that the patency rate is very satisfactory and can be the first choice of treatment for trans-acetabular lesions. Of course, with the development of new stents, the efficacy of endoluminal therapy is improving, but sufficient cases and long follow-up are still needed to provide more adequate evidence