Role of Femoral Endarterectomy as a Platform for Simultaneous Hybrid Inflow and Outflow Revascularization

Background/Objectives: Common femoral artery (CFA) disease often presents alongside multi-level arterial involvement, requiring complex revascularization. Traditionally, femoral endarterectomy (FEA) is the gold standard for CFA lesions due to its high durability. This study evaluates the role of FEA not merely as a localized treatment but as a strategic "platform" for simultaneous hybrid inflow and outflow revascularization. Methods: We conducted a retrospective, single-center analysis of 52 patients treated for CFA-involved peripheral artery disease between 2010 and 2025. Patients were divided into two groups: the Hybrid (-) Group (isolated FEA, n=23) and the Hybrid (+) Group (FEA combined with simultaneous endovascular inflow or outflow procedures, n=29). In the Hybrid (+) group, the FEA site served as a "hub" for retrograde iliac stenting or antegrade distal interventions. Outcomes measured included hemodynamic improvement, primary patency rates, and safety profiles. Results: Baseline demographics and cardiovascular risk factors were well-balanced between groups. Both groups showed significant postoperative ankle brachial index improvement (P < 0.001). The 10-year primary patency rate for the femoral segment was exceptionally high at 94.1%. Crucially, utilizing the FEA as a hybrid platform did not compromise the durability of the femoral reconstruction compared to isolated FEA (P=0.460). While inflow (iliac) patency remained stable at 94.1% over 10 years, outflow (distal) patency showed a progressive decline to 42.9% after five years. Regarding safety, the Hybrid (+) group did not show a significant increase in severe complications requiring readmission or re-procedure compared to the Hybrid (-) group (3.4% vs 4.3%, P=1.000). Interestingly, mild wound-related complications were significantly more frequent in the isolated FEA group (P=0.011). Conclusions: Femoral endarterectomy remains a cornerstone of treatment, providing a safe and effective gateway for comprehensive, single-session revascularization in patients with multi-level diseases. The hybrid platform approach optimizes hemodynamic outcomes and limb salvage without increasing the risk of severe surgical site complications or compromising the long-term patency of the femoral segment.