A breakthrough hybrid approach combining surgical precision with minimally invasive techniques is transforming outcomes for patients with chronic limb-threatening ischemia.
Imagine a critical highway intersection where three major roads meet: this is your femoral bifurcation, a crucial junction in your thigh where the main femoral artery splits into two smaller highways supplying blood to different parts of your leg. Now imagine this intersection completely blocked, with traffic at a standstill. For patients with severe chronic limb-threatening ischemia (CLTI), this isn't just a metaphor—it's a painful reality that puts their limbs and lives at risk.
When this anatomical intersection becomes clogged with plaque in a condition called atherosclerosis, it creates a circulatory crisis. Until recently, treatment options presented a difficult choice: invasive open surgery with a long recovery or minimally invasive approaches that often couldn't fully address complex blockages. But a remarkable hybrid approach that combines the best of both worlds—open surgical precision with endovascular flexibility—is now transforming outcomes for these patients. This article explores how surgeons are pioneering techniques to clear these life-threatening blockages and restore healthy blood flow to endangered limbs.
Peripheral artery disease affects over 200 million people worldwide, with chronic limb-threatening ischemia representing its most severe form.
The femoral bifurcation is located where the common femoral artery (CFA) divides into two important branches: the superficial femoral artery (SFA), which carries blood down the length of the leg, and the deep femoral artery (DFA), which serves critical thigh muscles. This anatomical junction is particularly vulnerable to plaque accumulation that can restrict blood flow.
Femoral bifurcation endarterectomy (FBE) has long been considered the gold standard treatment for severe blockages at this junction 2 . The term "endarterectomy" literally means "removing the inner lining of the artery"—precisely what this procedure accomplishes. Surgeons physically remove the atherosclerotic plaque that has built up on the arterial walls, effectively clearing the blocked passageways.
What makes FBE particularly valuable is its ability to thoroughly clear the bifurcation without leaving hardware behind that might obstruct the important deep femoral artery—a limitation that historically plagued stenting approaches in this area 2 . By preserving outflow through both branches, FBE creates a durable solution that has stood the test of time.
| Anatomical Term | Description |
|---|---|
| Common Femoral Artery (CFA) | Main arterial trunk in the thigh before bifurcation |
| Superficial Femoral Artery (SFA) | Continuation of CFA down the length of the leg |
| Deep Femoral Artery (DFA) | Major branch supplying thigh muscles |
| Femoral Bifurcation | Point where CFA divides into SFA and DFA |
While FBE excels at clearing the central junction, many patients present with more extensive disease—long segments of blockage extending further down the leg. This is where the hybrid approach demonstrates its remarkable advantage, combining targeted open surgery with broader endovascular repair.
A recent study evaluating this innovative strategy demonstrated its impressive potential 2 . The research followed 83 ischemic limbs from 81 patients with complex occlusive disease involving both the femoral bifurcation and long segments of other leg arteries. The approach was methodical: surgeons first performed open endarterectomy to clear the femoral bifurcation, then used endovascular techniques (EVT) to address the remaining blockages in distal segments.
| Outcome Measure | Pre-Procedure | Post-Procedure |
|---|---|---|
| Ankle-Brachial Index (ABI) | 0.39 ± 0.23 | 0.96 ± 0.25 |
| Dorsalis Pedis Pulse | Not reported | 70 patients regained pulse |
| Posterior Tibial Pulse | Not reported | 64 patients regained pulse |
The dramatic improvement in ABI—a key measure of circulatory function in the limbs—highlighted the procedure's immediate effectiveness. But even more impressive were the long-term outcomes, with primary patency (meaning the arteries remained open) rates of 90.24% at 12 months and 86.58% at 48 months 2 . These results demonstrated that the hybrid approach could offer both immediate relief and lasting protection.
Surgeons first use advanced imaging techniques to map the exact locations and extent of blockages, determining which areas require open surgery and which are suitable for endovascular approaches.
Through a precise incision at the femoral bifurcation, surgeons directly access the blocked arteries. They carefully open the vessels and remove the atherosclerotic plaque from the common, superficial, and deep femoral arteries, restoring flow through this critical junction.
Using the same access point, surgeons then introduce specialized guidewires and catheters that navigate through the newly cleared bifurcation and into the distal arteries.
For long-segment blockages further down the leg, surgeons employ various endovascular techniques—including angioplasty (inflating tiny balloons to compress plaque) and sometimes stenting—to reopen these narrowed passages.
The team uses real-time imaging (fluoroscopy) to confirm restored blood flow before carefully closing the surgical site.
This combined approach addresses a fundamental challenge in vascular surgery: open techniques provide superior results for complex bifurcations, while endovascular methods excel at treating long, straight segment blockages with less trauma. By integrating both methodologies, surgeons can tailor the solution to the specific anatomy of each patient's disease.
Modern vascular procedures rely on an array of specialized tools and technologies that enable surgeons to work with precision both in open surgical fields and within the intricate pathways of the vascular system.
Examples: Vascular clamps, dissectors, arteriotomy scissors
Enable precise opening and manipulation of arteries during the endarterectomy phase
Examples: Guidewires, balloon catheters, vascular stents
Facilitate navigation and repair of distal lesions through minimally invasive approaches
Examples: Fluoroscopy, ultrasound, angiography
Provide real-time visualization of vascular structures and blood flow
Examples: Ankle-brachial index (ABI) measurement, Doppler studies
Quantify circulatory impairment before surgery and monitor recovery afterward
The integration of these tools enables the comprehensive approach necessary to address complex vascular diseases. High-quality imaging identifies the problem, precision surgical instruments address the local junction blockage, and specialized endovascular equipment manages the extended disease—all working in concert to restore healthy circulation.
No surgical intervention is complete without considering the recovery process and long-term results. The hybrid approach demonstrates significant benefits in both these areas.
Complication Rate
Technical Success
Major Amputations
The study data revealed an impressive safety profile, with complications occurring in only 8.6% of cases 2 . These included minor issues such as lymphatic leakage and wound infections, along with more serious but rare events like distal thromboembolism. The high technical success rate of 100% across all patients underscores the procedural reliability.
| Time Post-Procedure | Primary Patency Rate |
|---|---|
| 1 month | 100% |
| 6 months | 96.34% |
| 12 months | 90.24% |
| 24 months | 87.71% |
| 48 months | 86.58% |
The long-term data tells a compelling story: the hybrid approach provides durable results that stand the test of time 2 . While some patients did experience restenosis (re-narrowing of the arteries), this was primarily associated with longer segment occlusions rather than failure at the surgically repaired bifurcation. Importantly, the research identified that postoperative mortality was linked to diabetes and advanced age rather than the procedure itself.
The most meaningful outcomes, however, were measured in preserved limbs and restored quality of life. During the follow-up period, only three patients required major amputation—a remarkable achievement for a population with chronic limb-threatening ischemia 2 . The combination of dramatically improved blood flow, high patency rates, and limb preservation demonstrates the profound clinical impact of this hybrid approach.
The hybrid approach combining femoral bifurcation endarterectomy with endovascular therapy represents more than just a technical advancement—it embodies a evolving philosophy in surgical care. By moving beyond the traditional boundaries between open and endovascular specialties, this method offers patients personalized solutions that address the full complexity of their vascular disease.
As vascular medicine continues to evolve, the principles demonstrated by this approach—anatomical precision, procedural flexibility, and patient-specific solutions—will likely guide future innovations. The remarkable success of this hybrid technique, with its excellent hemodynamic improvements and favorable long-term outcomes, positions it as a new standard for managing complex circulatory disorders 2 .
For patients facing the prospect of limb loss due to severe blockages, this surgical innovation represents hope—the promise of restored circulation, preserved limbs, and renewed quality of life. Through the continued refinement of these approaches, vascular surgeons are ensuring that life's critical pathways remain open, allowing patients to move forward on their own two feet.