Hybrid femoral-to-above-knee popliteal bypass with popliteal relining for complex femoropopliteal occlusive disease.

Objective: Complex femoropopliteal occlusive disease (CFPOD) involving superficial femoral artery occlusion with concomitant above-knee (AK) popliteal disease is commonly treated with femoral-to-below-knee popliteal bypass. However, outcomes are limited when autologous vein is unavailable and prosthetic conduits are used for infrageniculate targets. We explored a hybrid femoral-to-above-knee popliteal bypass (HYB) as an alternative treatment for CFPOD. Methods: HYB was performed in three patients by combining endovascular reconstruction of the popliteal artery using balloon angioplasty and covered stent graft relining to create a functional AK outflow segment with a femoral-to-AK popliteal bypass. The technical details of the procedure were described and illustrated. Operative data, clinical outcomes, and midterm graft patency were recorded. Results: Three patients with chronic limb-threatening ischemia and a history of failed interventions with no suitable vein conduit underwent HYB. Operative time was approximately 3 hours, and mean blood loss was 300 mL. Technical success was achieved in all cases, with no perioperative morbidity or mortality. All patients achieved limb salvage, sustained symptom relief, and maintained graft patency for at least 2 years, including one patient with follow-up beyond 3 years. Conclusions: HYB with popliteal relining may offer a durable alternative to prosthetic femoral-to-below-knee popliteal bypass in selected patients with CFPOD and limited conduit options. Larger comparative studies are needed to define long-term outcomes and optimal patient selection.