Superficial Femoral Artery Endarterectomy for Atherosclerotic Lower Extremity Occlusive Disease



Superficial Femoral Artery Endarterectomy for Atherosclerotic Lower Extremity Occlusive Disease



David H. Stone and Daniel B. Walsh


The role for superficial femoral artery (SFA) endarterectomy, either localized or remote (semiclosed), has assumed a less prominent role in current vascular surgical practice. Though described previously, these techniques have been largely supplanted by the well-established superior results of vein bypass for treating SFA occlusive disease. The advent and popularization of a myriad of percutaneous endovascular therapies for treating SFA disease has further rendered this technique less common. Nevertheless, persistent clinical scenarios arise where SFA endarterectomy still has a useful and viable role and can serve as a good option among selected patients.



Open Endarterectomy


Historically, the open endarterectomy technique (Edwards procedure), comparable to a standard carotid endarterectomy technique, incorporates a longitudinal arteriotomy that traverses the length of the diseased arterial segment, through which a standard endarterectomy is performed under direct vision. The artery is subsequently closed with a patch angioplasty technique using saphenous vein, bovine pericardium, or an alternative patch material in order to preserve vessel lumen diameter.


Initially, this technique was applied even to diseased long segments (>25 cm). However, it has since fallen out of favor for several reasons. First, it was regarded as too time-consuming and tedious. Closure of a long arteriotomy required a long incision, and it required both potential sacrifice of long segments of vein (that could be otherwise used for a bypass). Lastly, this technique sometimes resulted in aneurysmal dilation of the patch, creating the potential for thromboembolic complications or the need for an additional surgical revision. Consequently, this technique was abandoned for long-segment occlusions of the SFA.


Short-segment focal SFA lesions, by contrast, may still be amenable to endarterectomy techniques, particularly among patients who have failed endovascular revascularization or who have poor conduit options for a conventional bypass. Inahara and Scott initially described their results using this technique among 100 patients (85% for claudication), emphasizing good patient selection (lesion length <15 cm), a deep endarterectomy plane, beveling and tacking points of transition between endarterectomized and untreated arterial segments, and patching 1 to 2 cm beyond both endpoints. As expected, the majority of these procedures were confined to the distal third of the SFA (75%). Patency rates at 5 and 10 years were 70% and 50%, respectively. Thirty endarterectomies failed, of which 14 required no additional treatment, and 16 required femoropopliteal bypass. Although these results are laudable, they preceded the era of endovascular therapies for treating SFA occlusive disease. Accordingly, short-segment endarterectomy is usually not employed as a first-line therapy.



Semiclosed Endarterectomy


Cannon and Barker first described the semiclosed technique in 1955 in a report that introduced a fine wire loop stripper. The authors describe that once a cleavage plane was established between the lesion and the underlying media or adventitia at any point along the SFA, the plane could be safely developed and advanced within the unopened artery by insinuating a wire loop. In many respects, this technique heralded aspects of subintimal angioplasty in contemporary practice. With this technique, the entire length of the SFA could be disobliterated without opening the entire length of the diseased arterial segment. The authors reported technical success, defined as improvement in symptoms and restoration of the popliteal or pedal pulse, in 20 of 23 patients with claudication.


In another historical series, Walker and colleagues reported the results of 123 semiclosed SFA endarterectomies. All patients had patent popliteal arteries and at least single-vessel runoff. The endpoint was routinely managed with tacking sutures. Patency of the endarterectomized segment was 76% at 1 year and 46% at 5 years for the entire group. As anticipated, subgroup analysis demonstrated superior outcomes when this technique was used for treating claudication versus critical limb ischemia. Moreover, results were better among nondiabetics, likely reflecting the proclivity toward infrageniculate disease among those with long-standing diabetes.


More recently, remote superficial femoral endarterectomy (RSFAE) has evolved toward a hybrid technique, incorporating a small proximal incision in conjunction with stent placement at the distal transaction point, obviating the need for tacking sutures, as described in older series. Despite the evolution in technique, restenosis of the endarterectomized segment remains a challenging problem.


Several factors are likely responsible for restenosis following RSFAE. Derksen and colleagues, from the Netherlands, analyzed a group of 90 patients, in whom 57 (63%), who underwent RSFAE developed evidence of a restenosis (peak systolic velocity [PSV] ratio ≥2.5). Using multivariate analysis, the authors identified that age, duration of ischemic walking complaints, and lumen diameter were independently associated with an increased risk of restenosis after RSFAE.


Derksen and colleagues also attempted to identify unique histologic features of atherosclerotic plaque in the SFA that might make RSFAE prone to restenosis. In comparing histologic features of plaque among patients who underwent common femoral endarterectomy versus RSFAE, the authors noted that SFA plaques were more likely to have a higher collagen and smooth muscle cell content than their common femoral counterparts. By multivariate analysis, plaque collagen content was determined to be an independent predictor for restenosis following endarterectomy.

Related posts:

  1. Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease
  2. In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts
  3. Treatment of Acute Upper Extremity Venous Occlusion
  4. Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy

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Jul 15, 2018 | Posted by in CARDIOLOGY | Comments Off on Superficial Femoral Artery Endarterectomy for Atherosclerotic Lower Extremity Occlusive Disease

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