Dual Incision Remote Endarterectomy Is a Novel Treatment Option for Long-Segment Superficial Femoral-Popliteal Artery Occlusive Disease

Abstract

Objectives: Remote endarterectomy (RE) is a minimally invasive procedure conceived as an alternative to an above-the-knee bypass for patients with symptomatic limb ischemia. Successful RE outcome is frequently hampered by adherent plaque within and beyond the adductor canal and the insertion of a stent. We present a case series of modified RE enhanced by the addition of a distal leg incision to accomplish a longer segment plaque excision without the need for a distal stent. Methods: A retrospective record review identified RE procedures performed from May 2010 through March 2012. Adjunctive patch angioplasty was used to close the arteriotomies. Demographics, lesion characteristics, procedural details, andoutcomedatawere collected. Study endpointsweredeath, occlusion, reoperation, or last office follow-up visit. Results: REwas performed in 11 patients (5men;mean age, 68 years, 3 diabetics, 11 tobacco users). Indication for operation was claudication in 6, rest pain in 3, and gangrene in 2.REwas technically successful in all patients.Distal arterial exposure was above knee in 7 (64%), below knee in 2 (18%), and combined above-knee and below-knee exposures in 2 patients (18%). Two patients underwent concomitant balloon angioplasty in either the popliteal or anterior tibial vessels. Mean postoperative ankle-brachial index increase was .43 (P 1⁄4 .001). Operative complication of above-knee popliteal artery perforation occurred in one patient but was successfully repaired with covered stent deployment. Average procedure duration was 162 6 69 minutes (standard deviation) and average hospital stay was 4 days. All patients reported symptom resolution; both patients with tissue ulceration healed. During the 12-month follow-up period, a femoropopliteal reocclusion developed in four patients, resulting in one patient who underwent a successful femoral-popliteal bypass operation. Limb salvage rate was 100%. Conclusions: When endovascular therapies are exhausted, and should autologous saphenous vein be unavailable, the dual incision RE technique of long segment femoropopliteal occlusive lesions accomplishes effective revascularization. Symptom relief or limb salvage was achieved in all patients; the need for a subsequent bypass was rare and not adversely affected by having undergone the dual incision RE.