Efficacy and Safety of Endovascular Therapy with Common Femoral Artery Endarterectomy Site Access in Patients with Lower Extremity Artery Disease

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The Role of Common Femoral Artery Endarterectomy in the Endovascular Era

Long-term results of combined common femoral endarterectomy and iliac stenting/stent grafting for occlusive disease

Open and endovascular treatment of the common femoral artery in a tertiary care center

Common femoral artery endarterectomy (CFE) is the standard treatment for common femoral artery occlusive disease. We aim to assess the medium term outcomes of CFE with or without further concomitant procedures. A retrospective observational study. All patients who underwent either isolated CFE (ICFE), CFE with angioplasty for occlusive arterial disease (CFEA) or concomitant CFE with endovascular aortic aneurysm repair (CFEE) were included. Patient demographics follow up, clinical improvement, types of CFE closure, patency rates, and survival-free amputation were noted. From 2002 to 2015, 1512 patients were referred with a diagnosis of critical limb ischemia. Of those, 1134 required revascularization. Sixty-one patients underwent 66 CFE. Ten limbs underwent an ICFE, 35 had CFEA, and 21 underwent CFEE. Demographics were comparable in all groups. Twenty-seven were closed primarily, while 39 required patch closure (12 venous, 8 Dacron, 19 biological). Technical success was 100% in ICFEs, 94% in CFEA, and 100% for CFEE ( p = 0.274). Immediate clinical success was 100% in both CFE and CFEE, but was 85.7% in CFEA ( p = 0.035). Immediate hemodynamic success was similar in all three groups ( p = 0.73). Sustained hemodynamic success was 30% in ICFE, 54.3% in CFEA, and 23.8% in CFEE ( p = 0.056). At two years, the primary patency was 90% in ICFE, 74.3% in CFEA, and 100% in CFEE ( p = 0.049). Primary-assisted patency was 90% in ICFE, 82.9% in CFEA, and 100% in CFEE ( p = 0.17). Secondary patency was 90% in ICFE, 94.3% in CFEA, and 100% in CFEE ( p = 0.409). Re-intervention was required in 26.9% of primary closures, versus 12.8% with patch closures ( p = 0.279). Amputation-free survival was 100% in ICFE, 80% in CFEA, and 100% in CFEE ( p = 0.056). CFE is a reliable and dependable procedure, even in the absence of good distal runoff.

Midterm Outcomes of Common Femoral Endarterectomy Combined with Inflow and Outflow Endovascular Treatment for Chronic Limb Threatening Ischaemia

PurposeAlthough common femoral artery endarterectomy (CFAE) is regarded as the standard treatment modality for common femoral artery (CFA) disease, availability of advanced endovascular techniques has resulted in an increased number of CFA disease being treated. We evaluated clinical outcomes in a contemporary series of patients who were treated for CFA disease using endarterectomy alone or combined with endovascular treatment.Materials and MethodsWe retrospectively reviewed 46 patients from November 2001 through December 2007. The treated lesions were divided into 4 groups based on operative procedure: group I (n=11), CFAE alone; group II (n=15), CFAE and iliac artery (IA) endovascular treatment; group III (n=6), CFAE and superficial femoral artery (SFA) endovascular treatment; group IV (n=14), CFAE and IA and SFA endovascular treatment or bypass surgery.ResultsThe degree of CFA steno-occlusion was not different among the groups. The 3-year primary patency rates of each group were 88.9±10.5%, 60.0±14.5%, 62.5±21.3%, and 83.9±10.4%, respectively. The 3-year primary assisted patency rates were 100%, 70.0±13.0%, 62.5±21.3%, and 89.3±10.4%, while 3-year secondary patency rates were 100%, 80.0±13.0%, 62.5±21.3%, and 92.3±7.4%, respectively. There was no procedure-related mortality. Significant improvement of ankle-brachial index was achieved in all groups.ConclusionCFAE alone is the treatment of choice for excellent patency and clinical improvement in steno-occlusive lesions confined to the CFA. In multiple steno-occlusive diseases, this procedure could be combined with endovascular procedures to reduce the operative risk in conditions with high morbidity.

To investigate the efficacy and safety of combined common femoral artery (CFA) endarterectomy with superficial femoral artery (SFA) stenting plus Shuxuening Injection infusion in patients with complex multifocal arterial steno-obstructive lesions of the lower extremities. From March 2006 to March 2011, 104 lower limbs in 96 patients with multilevel peripheral arterial steno-occlusive disease, involving SFA as well as CFA and deep femoral artery (DFA) orifice, were treated by combined surgical with endovascular therapy, such as SFA stenting as an adjunct to CFA endarterectomy and patch angioplasty with the great saphenous vein. Before the end of the operation, 20 mL of Shuxuening Injection was infused through the catheter located in the treated artery. Technical and hemodynamic success, as well as primary and primary-assisted patency, was determined according to the Society for Vascular Surgery Guidelines. During follow-up, clinical status assessment, ankle-brachial index (ABI) test, and duplex Doppler ultrasound were administered every 6 months, and computed tomography angiography or magnetic resonance angiography was performed at 12, 24, and 36 months after discharge. All patients underwent successful combined CFA endarterectomy with SFA stenting treatment. The average ABI after the combination treatment increased from pretreatment of 0.32±0.21 to 0.82±0.24 (P<0.01). No perioperative death and major limb amputations occurred. The mean duration of follow-up for 104 limbs from 96 patients was 1,180 days (range, 196-2,064 days). During follow-up, 5 patients died due to myocardial infarction, cerebral infarction, or pneumonia, and 5 patients were lost to follow-up. There were 21 cases (21.4%) of restenosis, with 15 that occurred in-stent and 6 near the distal end of the stent. A total of 18 (18.3%) reinterventions were performed, including 6 balloon angioplasty, 8 restenting procedures, 2 bypass surgeries, and 2 major limb amputations. The primary patency rates were 92.2%, 76.8%, and 61.3% at 12, 24, and 36 months, respectively, while the primary-assisted patency rates were 94.4%, 83.2%, and 75.6% at 12, 24, and 36 months, respectively. The combined CFA endarterectomy with SFA stenting plus Shuxuening Injection infusion appears to offer a safe, less invasive, and effective treatment option to patients with chronic lower extremity ischemia due to complex multifocal peripheral artery disease.

Introduction: The common femoral artery (CFA) is often affected by atherosclerosis in patients with peripheral arterial disease, requiring revascularisation. Open surgical CFA endarterectomy (CFAE) remains the standard of care in this context; however, there have been multiple recent advances in endovascular CFA therapies. However, randomised controlled trials (RCTs) comparing CFA treatments have suffered from multiple pitfalls. This research aimed to assess opinions regarding potential barriers and enablers of delivering a high-quality RCT of open surgical CFAE versus endovascular CFA therapy. Methods: A mixed-methods qualitative study was performed, including a structured online survey and face-to-face semi-structured interviews with healthcare professionals. Survey content and interview topic guides were developed following a literature review to identify ongoing and completed RCTs comparing CFA treatments. The data were analysed using thematic analysis. Results: The online survey was completed by 121 participants, including vascular surgeons (n=75, 62%) and interventional radiologists (n=22, 18%), mostly from the UK (n=92, 76%). A total of 61 participants (51%) would be willing to take part in an RCT comparing open versus endovascular CFA revascularisation. The majority (n=89, 74%) believed that such an RCT is urgently needed. Fifteen participants were interviewed face-to-face. Five main themes emerged regarding barriers and facilitators for a high-quality RCT in this context: factors directly limiting patient recruitment; clinicians’ attitudes towards equipoise between treatments; clinicians’ attitudes towards endovascular therapies; attitudes towards outcomes examined in a potential RCT; and factors facilitating patient recruitment. From these, 10 sub-themes were identified. Conclusion: The majority of survey respondents believed an RCT comparing open and endovascular CFA revascularisation is necessary and would participate in such a trial. Important barriers and enablers, grouped in five overarching themes, have been identified, which would require serious consideration when designing and delivering such an RCT.

Editor's Choice – Eligibility of Common Femoral Artery Atherosclerotic Disease for Endovascular Treatment – the CONFESS Study

Common Femoral Artery Endarterectomy for Lower-Extremity Ischemia: Evaluating the Need for Additional Distal Limb Revascularization

Endovascular therapy has gradually gaining more importance for the treatment of common femoral artery (CFA) occlusive disease due to satisfactory perioperative outcomes. However, endovascular interventions seem to provide acceptable outcomes only in the short-term period. Endarterectomy still remains the gold standard with well-established mid- and long-term outcomes. The aim of this study was to analyze all appropriate studies about mid- and long-term outcomes of CFA endarterectomy, regardless of the type of technique used in the framework of a narrative contemporary review. This narrative review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The main inclusion criterion was the availability of data on isolated CFA endarterectomy including mid (1-5 years) and long (6-10 years) term results. Four studies have been selected. In the mid-term period CFA endarterectomy showed an excellent primary patency rate regardless the clinical presentation (up to 95% and 100% in intermittent claudication and chronic limb-threatening ischemia). About the type of reconstruction, a statistically significant difference was found between patchplasty and direct suture in terms of primary patency (97% vs. 89.9%, P=0.02). In the long-term period the overall primary patency rate was about 95%, regardless of the clinical condition (P=0.04). Overall long-term limb salvage rate ranged from 87% to 92%, with a relatively significant difference between intermittent claudication (100%), and chronic limb-threatening ischemia (82%) (P=0.01). Considering long-term clinical outcomes and the subsequent durability, surgical treatment is still the cornerstone for CFA occlusive disease, regardless of the type of technique used for both endarterectomy and arterial reconstruction. Due to its reduced invasiveness, high-risk patients may benefit from an endovascular-first approach.

Although common femoral artery endarterectomy (CFE) is the standard treatment for occlusive disease of the common femoral artery (CFA), several studies have noted encouraging results for endovascular therapy in this anatomical area. A retrospective multi-center study of 118 consecutive limbs from 111 symptomatic patients undergoing CFE between April 1998 and December 2014 was performed. Seventy-five CFE were performed on limbs for intermittent claudication and 43 CFE were performed for critical limb ischemia (CLI). The prevalence of perioperative complications was higher in patients with CLI than in the claudication patients. The technical success rate was 99% in all cases. The 1- and 5-year primary patency rates were 100% and 100% for claudication and 95% and 95% for CLI, respectively. The assisted-primary patency rates were 100% at both time points in both groups. Freedom from major amputation at 1 and 5 years was 100% and 100% in the claudication patients and 93% and 82% in the CLI patients, respectively. The 1- and 5-year overall survival rates were 97% and 89% in the claudication patients and 69% and 33% in the CLI patients, respectively. CFE is a safe, effective and durable procedure for occlusive disease of the CFA. This procedure should remain the standard treatment for this anatomical region.

Introduction: Common femoral artery endarterectomy (CFE) is considered a relatively simple, successful and safe procedure in the literature, but major complications can occur. This retrospective study was performed in order to define characteristics contributing to success or failure after common femoral artery endarterectomy, either performed as a single or hybrid procedure. Methods: A total of 298 patients who underwent CFE in our hospital between 1 January 2011 and 1 January 2017 were included. After exclusion, 227 patients were analyzed. Patient characteristics and outcomes were derived from the patient records. Follow-up was 30 days postoperatively. Outcomes were analyzed by the chi-square test and regression analysis. Clinical success was defined as a combination of technical success, improvement in the ankle-brachial index, increased walking distance and “no complications.” Results: The procedure was clinically successful in 74.4% of the patients, and in 25.6%, a complication occurred. The Rutherford class improved in 65.1% of the patients with 1.6 (SD 1.3) class points. The ankle-brachial index improved in 44.8% of the cases, with an average of 116.6%. The most contributing factors for complications such as death, unplanned amputation, surgical site infection, thrombosis and longer hospital admission were emergency operation and a higher ASA classification. Significantly more complications also occurred in patients with renal failure, congestive heart disease, a high Rutherford classification and previous groin incision. A higher Rutherford class was the only factor correlating with an increase in the ankle-brachial index. When single CFE (48.9% of cases) and hybrid procedures (51.1%) were compared, no significant difference in success or failure was found. Conclusion: Limb ischemia requiring emergency operation and preoperative comorbidity were identified as the most important factors predictive for complications following femoral artery endarterectomy. Combining femoral endarterectomy with an endovascular intervention does not seem to increase the risk of a postoperative complication.

Aim To evaluate the safety and efficacy of one-stage hybrid revascularization modality in patients with complex multifocal arterial occlusive lesions. Patients and methods A prospective study design was established. Included patients were those admitted to the Vascular and Endovascular Surgery Department between November 2015 and November 2016 and presenting with Rutherford stages 5 and 6 critical limb ischemia due to multilevel arterial occlusion involving common femoral artery and one or both of inflow (iliac) and outflow arteries (superficial femoral and leg arteries) with nonsignificant aortic lesions and underwent a one-stage hybrid revascularization procedure aiming limb salvage. Common femoral artery endarterectomy was a fixed step in all cases. For inflow lesions; plain balloon angioplasty with bare metal stenting was first attempted then a femoro-femoral bypass if failed the endovascular approach. For outflow lesions, plain balloon angioplasty with selective stenting was tried in all cases and to stop if failed provided the presence of sufficient profunda flow. The study end points were 1-year primary patency, secondary patency, limb salvage, and complication rates. Results This study included 30 patients (30 limbs), with a mean age of 65±10.28 years. Technical success was achieved in 46 (95.8%) of 48 performed procedures and hemodynamic or clinical success in all patients (100%). Twelve-month primary and secondary patency rates were 67 and 80%, respectively. One-year limb salvage rate was 93.3%. Postoperative complications were reported in four (13.3%) cases. Conclusion One-stage hybrid procedures may be considered a safe and effective modality in the treatment of patients with critical limb ischemia due to multilevel complex arterial occlusions.