Imaging and Labs Preprocedure planning with noninvasive imaging such as computed tomography angiography, magnetic resonance angiography, or invasive angiography assists the operator in developing an optimal hybrid surgical and endovascular plan. Specifically, appropriate operatory or interventional laboratory requirements, patient positioning, suitability of various access points, appropriate equipment selection, and any case-specific anatomic complexities can be reviewed before intervention. Previously, less complex lesions were targeted for endovascular interventions with surgical management reserved for more complex disease or lengthy chronic total occlusions. However, with advancement in endovascular-based technologies and operator skill set, percutaneous interventions are often used even for complex Trans-Atlantic Intersociety Consensus (TASC) C or D lesions.

Drugs Typically, hybrid procedures are performed with general anesthesia in an operating room with a mobile fluoroscopy unit capable of performing digital subtraction angiography. Dual-antiplatelet loading is usually delayed until after the intervention to lower immediate surgical bleeding risk, especially in case of unforeseen complications. Preoperative prophylactic intravenous antibiotics are typically provided to prevent infection. After surgical exposure of the vessels and before vessel clamping or sheath insertion, intravenous heparin is administered to target an activated clotting time of twice the upper limit of normal.

Endarterectomy In the case of occlusive aortoiliac disease extending into the ipsilateral common femoral bifurcation, surgical common femoral endarterectomy is typically performed first. A longitudinal common femoral arteriotomy is made and can be extended proximally into the distal external iliac artery or distally into the proximal superficial and deep femoral arteries just beyond the bifurcation. After endarterectomy is performed and the obstructing plaque is removed, the arteriotomy is closed with a patch angioplasty (using autogenous vein graft or synthetic or biologic material) or interposition synthetic graft.

Endovascular Technique Following surgical endarterectomy, the inflow iliac lesion is then approached via endovascular technique. Contralateral standard retrograde femoral access is obtained percutaneously, and a distal aortic angiogram is pursued if one has not been obtained previously. For lesions involving the external iliac artery, contralateral access may be sufficient if there is enough length over the bifurcation to allow positioning of a long sheath with adequate support. For lesions involving the proximal or ostial common iliac artery, a sheath is placed into the ipsilateral surgically exposed and reconstructed femoral artery to perform the endovascular intervention, which typically is successful using solely a wire and catheter technique for lesion crossing. Bare-metal balloon-expandable stents are generally used within the common iliac segment given their stronger radial force and use in ostial lesions, whereas self-expandable bare-metal stents are often used within the external iliac segment, particularly in tortuous vessels, given their conformability.