Choosing the Optimal Surgical Treatment Tactics for Multilevel Arterial Damage of the Lower Extremities in Patients with Critical Ischemia, Depending on the Level of Peripheral Vascular Resistance and the Condition of the Deep Femoral Artery

Introduction. Multilevel atherosclerotic lesions of peripheral arteries are the main cause of decompensation of blood circulation with the development of critical ischemia of the lower extremities. Currently, there is an ongoing discussion about the expediency of supplementing the intervention on the aorto-femoral segment with a single-stage femoral-popliteal reconstruction. However, to clearly define the tactics of revascularization of multilevel lesions, it is necessary to conduct a comparative analysis of the long-term results of various types of revascularization operations, depending on the level of peripheral vascular resistance and the condition of the deep femoral artery.
Aim. To evaluate the results of various revascularization operations and develop differentiated tactics for surgical correction of blood flow in patients with multilevel atherosclerotic lesions of the lower extremity arteries, depending on the level of peripheral vascular resistance and the presence or absence of hemodynamically significant lesions of the deep femoral artery.
Material and Methods. A retrospective study conducted on the basis of the Vascular Surgery Department of the St Petersburg City Multidisciplinary Hospital № 2 included 379 patients observed between 2013 and 2025. 217 patients were re-hospitalized. A combined lesion of the aorto-femoral and femoral-popliteal segments (FPS) was found in all patients. The level of peripheral vascular resistance was assessed according to the method proposed by R. B. Rutherford, with changes by A. V. Pokrovsky in the modification of L. A. Maslov.
Results. In the analysis of the results of various methods of revascularization of multilevel atherosclerotic lesions of lower extremity arteries over 144 months with isolated reconstruction of the aorto-femoral segment and simultaneous revascularization of the aorto-femoral and femoro-popliteal segments, the best results of primary and secondary patency were noted in the groups of open and hybrid interventions compared with endovascular surgeries (p<0.05). At the same time, the primary patency of the reconstructed FPS was significantly worse in the group with high peripheral vascular resistance (PVR) (p<0.05), and did not significantly depend on the fact of performing femoro-profundoplasty (p >0.05). The rates of freedom from reinterventions and the number of preserved limbs in the group of simultaneous interventions were significantly lower than in isolated reconstruction and directly depended on the level of peripheral vascular resistance (p<0.05).
Conclusions. In most cases, isolated reconstruction of the aorto-femoral segment is the tactic of choice to achieve optimal revascularization in patients with multilevel vascular lesion. Additional reconstruction of the femoral-popliteal segment may be recommended if the clinical manifestations of significant ischemia in the distal parts of the lower extremities persist. Assessment of the value of peripheral vascular resistance allows predicting the immediate and long-term results of revascularization, regardless of the type of surgical intervention.

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