Deep Femoral Patch Angioplasty for Atherosclerotic Occlusive Disease of the Lower Extremity

Ramon Berguer

Angioplasty of the deep femoral artery was first used as a technical improvement in aortofemoral bypass operations in patients with occluded superficial femoral arteries. Creating an arteriotomy along the anterior wall of the deep femoral arterial trunk and suturing the toe of the beveled graft to it, in the form of an angioplasty, became standard practice in the 1960s.

It was primarily the work of Martin’s group at Hammersmith Hospital in England that aroused interest in isolated surgical reconstruction of the deep femoral artery to improve blood flow to the leg in patients with symptomatic atherosclerotic occlusions of the arteries of the thigh and leg. In patients with occluded superficial femoral arteries, the deep femoral artery is the main arterial inflow to the leg.

The origin of the trunk of the deep femoral artery is often involved by an atheromatous plaque that extends from the common femoral artery. In these patients a 1-mm thickening in the trunk of the deep femoral artery represents a 78% stenosis in the inflow to the leg. Beales and colleagues noted that these deep femoral artery stenoses were often missed in arteriograms obtained in the standard anteroposterior projection. The oblique views of the groin that they advised revealed unsuspected disease in 68% of the patients. Thus, stenoses of the trunk of the deep femoral artery were, contrary to what was believed till then, quite common.

Given that the deep femoral artery forms the main thigh collateral channel in patients with an occluded superficial femoral artery, it made sense to correct any stenosis at the inflow with an angioplasty so as to improve perfusion in the popliteal artery and its branches. Such an angioplasty, with or without endarterectomy of the deep femoral artery, was a limited procedure that could be done with the patient under spinal or local anesthesia. It was simpler than a femoropopliteal bypass reconstruction, and it did not require the availability of a suitable autogenous vein.

Indications

Most of the early series of deep femoral artery angioplasties were reported in the early 1970s. In some cases, the operation was used in patients who did not satisfy the primary requirements for femoropopliteal bypass: a saphenous vein of good caliber and a patent popliteal artery and branches. In others, it was used instead of a femoropopliteal bypass. Some authors performed deep femoral artery angioplasties only in patients who had demonstrable severe stenosis at the origin of this vessel. Others did patch angioplasty of this vessel in the absence of a discrete stenosis of its origin on the assumption that the trunk of the deep femoral artery in itself represented a functional stenosis between the common femoral artery and the point of branching of the deep femoral arterial trunk.

Short-term results following a profundoplasty showed improvement over 1 to 2 years in the majority of patients with claudication, but the deep femoral artery angioplasty did not help those patients with severe rest pain or gangrenous changes. Patients who reported symptomatic improvement following extended deep femoral artery angioplasty had a significant increase in flow velocity between the preoperative and postoperative measurements obtained in the operating room. They also exhibited a substantial increase in velocity after the intrarterial injection of papaverine, proof that the inflow trunk of the deep femoral artery could now accept the increased demand of flow expected with exercise. About 10% of patients, primarily those with a good set of thigh collaterals, recover a distal foot pulse after patch angioplasty.

Conversely, patients who did not improve clinically did not have any significant change in the postoperative flow velocity. Arteriography in these patients documented that patients with severe disease of the popliteal and infrapopliteal vessels rarely benefited from the procedure. Although the inflow to the thigh collateral channels was improved in this latter group of patients, the maximum resistance to flow that was located at the level of the knee or below negated the expected effectiveness of the more proximal procedure. A limited series published in 1979 reported that no patient with an ankle-to-brachial index below 0.30 had a successful result from deep femoral angioplasty. Patients with constant rest pain and gangrenous changes did not improve.

Even though the operation involved limited surgical dissection, it carried a substantial mortality of 2% to 4%, with most patients dying from myocardial infarction, probably a reflection of the extent of atherosclerotic disease in this population. As the results of long-term studies became available, there was a sobering reevaluation of the claims made in the earlier reports. Loss of continuous patency was noted beyond a 2-year follow-up period, with diabetic patients faring worse than those without diabetes. Eventually, newer techniques for infrapopliteal bypass reconstruction were refined and came into general use, and the interest in deep femoral artery angioplasty faded. The operation was reserved for claudicants with disease of the trunk of the deep femoral arteries, good thigh collaterals, and patent popliteal arteries.

The first series of percutaneous transluminal angioplasty of the deep femoral artery were published in 1980. Balloon angioplasty was generally done by accessing the contralateral femoral artery. There were reports of difficulties doing angioplasty of the origin of the deep femoral artery when it is involved with severely calcified plaque. This plaque is continuous with the plaque in the posterior wall of the common femoral artery.

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