Hybrid iliofemoral revascularization: a bicentric experience in high-risk patients with aorto-iliac-femoral occlusive disease

BACKGROUND: Hybrid iliofemoral revascularization has emerged as an alternative to extensive open reconstruction in patients with complex aorto-ilio-femoral occlusive disease. This study reports a bicentric real-world experience, focusing on mid-term outcomes and the impact of iliac stent configuration on patency and reintervention. METHODS: A retrospective bicentric analysis included consecutive patients undergoing hybrid iliofemoral revascularization between January 2010 and December 2023. All procedures combined common femoral artery (CFA) reconstruction with endovascular iliac revascularization. Primary endpoints were technical success, restenosis, and reintervention. Secondary endpoints included peri-operative complications, limb loss, and mortality. Time-to-event analyses were performed on an available-case basis. RESULTS: A total of 174 patients were included (mean age 65.8±8.7 years; 83.3% male). Chronic limb-threatening ischemia was present in 65.5%, and iliac lesions were predominantly TASC D (85.0%). Technical success was achieved in 95.4%. Peri-operative complications occurred in 6.9%, with two major amputations and two deaths within 30 days. During a median follow-up of 24 months, restenosis occurred in 21.8% and reintervention in 16.1%. Freedom from restenosis or reintervention was approximately 84% at 1 year and 76% at 5 years. Among stented patients, covered or mixed covered + bare stent configurations were associated with a significantly lower hazard of restenosis or reintervention compared with bare-metal stents (adjusted HR 0.21, 95% CI 0.06-0.72; P=0.013), with a particularly strong association for reintervention alone (adjusted HR 0.08, 95% CI 0.01-0.59; P=0.013). CONCLUSIONS: Hybrid iliofemoral revascularization is safe and durable in a high-risk population with advanced disease. Iliac stent configuration appears to be a modifiable determinant of mid-term outcomes, supporting a tailored hybrid strategy beyond the binary open-versus-endovascular paradigm.