Common Femoral Artery Disease Research Articles

Endovascular as an Open Adjunct: Use of Hybrid Endovascular Treatment in the SFA

While open or endovascular techniques for treatment of the superficial femoral artery continue to dominate the care of most patients, there are clearly patients who benefit from a combination of these approaches. Typically these patients require treatment of more than a single level of disease. In these cases, endovascular treatment of one level is combined with surgical treatment at a second level of disease. Most commonly these involve surgical treatment of common femoral artery disease with endovascular treatment of the superficial femoral artery on either side or endovascular treatment of the superficial femoral artery combined with distal origin vein bypass. These approaches allow care to be delivered in a single setting, avoiding the issues of staged procedures. Although the published results from hybrid treatment are limited, the obvious patient benefit ensures that these techniques will continue to be important for vascular patient care.

Editorial note

Atherosclerotic disease of the common femoral artery (CFA), commonly associated with multilevel disease affecting the femoropopliteal segment, can cause claudication or contribute to critical limb ischemia. Although endovascular therapy for the management of peripheral arterial disease (PAD) has been increasingly utilized, its role in CFA lesions remains controversial. The aim of this study was to investigate the safety and efficacy of drug (DCB) vs non drug coated balloon angioplasty (BA) at the CFA segment.In this two-center study, we identified 154 patients treated either with DCB (n = 47) or BA (n = 107) for CFA lesions. Hazard ratios (HR) and the respective 95% confidence interval (CI) were synthesized to examine the association between the two groups in terms of target lesion revascularization (TLR), limb loss, and major adverse limb event (MALE) at 12 and 24 months of follow up.This real-world population included a high percentage of patients with critical limb ischemia (43%) and moderate to severe lesion calcification (75%). Adjunctive atherectomy was performed in 97.9% of DCB cases (N = 46/47) and 44.7% of BA cases (N = 51/114). The overall procedural success rate was 95% without any differences between the two groups. Post-angioplasty dissections were observed in 15 cases [DCB: 8.5% (N = 4/47) vs BA: 9.7% (N = 11/113); p = .81], while distal embolization occurred in one patient in the DCB group and one in the BA group (p = .52). Provisional stenting was more commonly necessary in BA vs. DCB cases (12.3% vs 2.13%, p = .044). Physiologic assessment during follow up demonstrated a better mean 2-year ABI for the DCB group (mean: 0.9; SD: 0.2) vs BA group (mean: 0.6; SD: 0.4), although statistical significance was not reached (p = .06). No difference between the two groups was detected in terms of freedom from TLR (DCB: 75.5% vs BA: 86.8%; HR: 1.31; 95% CI: 0.46–3.67; p = .61), freedom from limb loss (DCB: 83.8% vs BA: 83.6%; HR: 1.04; 95% CI: 0.36–2.99; p = .94) or freedom from MALE (DCB: 83.5% vs BA: 78%; HR: 0.73; 95% CI: 0.26–1.99; p = .53) at 24 m of follow up. However, at the end of follow up more deaths were observed in patients treated with BA than DCB (DCB: 14.9% vs BA: 31.7%; p = .03). Patients who required provisional stenting were at higher risk for limb loss 2 years after the initial procedure (multivariate: HR: 4.54; 95% CI: 1.09–18.85; p = .04).Both DCB and non-DCB strategies are effective modalities for revascularization of patients with CFA lesions. Larger prospective studies are necessary to determine the relative benefit, if any, of drug-eluting technologies for the treatment of common femoral artery disease.

Adventitial Cystic Disease of Common Femoral Artery

Adventitial cystic disease (ACD) is an uncommon cause of ischemia. The majority of ACD is located in the popliteal artery. Over 49 extrapopliteal locations have been described. We report on a case of femoral artery ACD in a young patient with claudication. The diagnosis was made with duplex ultrasound and confirmed with computed tomographic angiogram. The patient underwent a surgical treatment. One year postoperatively, the patient is active with no claudication. To our knowledge, this is the first reported case of extrapopliteal artery ACD in Canada.

Stent-Graft Repair of Aorto-Iliac Occlusive Disease Coexisting with Common Femoral Artery Disease

Significant disease or occlusion of the common femoral artery may preclude percutaneous therapy for aorto-iliac occlusive disease. In addition, aorto-iliac angioplasty may not reverse the ischemic symptoms when common femoral artery disease exists. The authors describe the feasibility of endoluminal stent-grafts to treat multilevel aortoiliofemoral occlusive disease. The authors placed 18 stent-grafts for aorto-iliac occlusive disease in 17 patients with limb-threatening ischemia and significant common femoral artery disease. These procedures were performed as a joint effort between vascular surgery and interventional radiology staff in the operating room. The common femoral artery was occluded in 10 or severely diseased in eight, necessitating endoluminal bypass to the superficial femoral or popliteal artery (n = 7) or to the deep femoral artery (n = 7), or necessitating patch angioplasty of the common femoral artery (n = 4). Stent-grafts were fabricated from 6-mm polytetrafluoroethylene and 29-mm Palmaz stents. All 18 grafts were placed successfully. Follow-up ranged from 3 to 38 months (mean, 21 months). Seven patients died of myocardial infarction; two grafts occluded and one required angioplasty during follow-up, resulting in a primary patency rate of 81% at 2 years. Endoluminal stent-graft placement is a useful method of treatment for advanced atherosclerotic aorto-iliac disease, particularly in the presence of common femoral artery disease. This approach avoids an extra-anatomic bypass or a major transabdominal aortic bypass procedure. Longer follow-up with a larger series is needed to ensure the safety and late graft patency comparable to the traditional aortofemoral and iliofemoral bypass grafts.

The asymptomatic carotid stenosis: Operative results

Only a few operative or interventional studies have addressed the issue of isolated arterial occlusive disease at the femoral bifurcation, the early and late results reportedly being favorable in the former, controversial in the latter. The purpose of this study was to analyze the peri-operative (30-day) and long-term outcomes of isolated surgical endarterectomy in patients with occlusive disease at the common femoral artery (CFA), providing a baseline for comparison with emerging endovascular procedures.Over an 8-year period, all consecutive patients referred to our institution for claudication, rest pain, nonhealing ulcer(s), or minor tissue loss, with imaging findings of CFA occlusive disease (isolated or with additional infrainguinal lesions in the ipsilateral limb) amenable to endarterectomy of the CFA (isolated or combined with a profundoplasty or with the endarterectomy of the superficial or deep femoral artery first tract, not >1 cm long) were enrolled in the study. We excluded all patients with major tissue loss for which a contemporary infrainguinal revascularization was performed because treating the inflow disease alone would not be sufficient to heal the ischemic wound(s) owing to the presence of concomitant femoral and/or distal lesions, inadequate collateralization, or poor runoff. Descriptive demographic data, risk factors, clinical manifestations, and operative details were recorded. Primary patency (PP), assisted PP (APP), and limb salvage (LS) rates, freedom from additional proximal or distal revascularization in the ipsilateral limb, and survival were assessed using Kaplan–Meier life tables. Univariate and multivariate analyses were performed to identify which factors could influence CFA segment patency or other parameters.In all, 117 patients were enrolled and underwent 121 CFA endarterectomies, 60.3% for claudication and 39.7% for critical limb ischemia (CLI); 30 patients were excluded because they underwent a contemporary infrainguinal revascularization. All procedures were performed with patients under regional anesthesia and took an average operating time of 1.3 ± 0.7 hours. There were no perioperative deaths or major complications, but 8 (6.6%) local complications. A complete follow-up (mean 4.2 years) was obtained in 111 patients (115 limbs). The 7-year PP, APP, and LS rates were 96%, 100%, and 100%, respectively; the 7-year rates of freedom from further revascularization and survival were 79% and 80%, respectively.Operative endarterectomy in patients with claudication or CLI for occlusive CFA disease proved safe, effective, and durable, and should provide a baseline for comparison with endovascular treatment. Proponents of endovascular procedures as a routine alternative treatment option should bear this in mind.

Carotid to petrous carotid bypass for lesions of the upper cervical carotid artery

Only a few operative or interventional studies have addressed the issue of isolated arterial occlusive disease at the femoral bifurcation, the early and late results reportedly being favorable in the former, controversial in the latter. The purpose of this study was to analyze the peri-operative (30-day) and long-term outcomes of isolated surgical endarterectomy in patients with occlusive disease at the common femoral artery (CFA), providing a baseline for comparison with emerging endovascular procedures.Over an 8-year period, all consecutive patients referred to our institution for claudication, rest pain, nonhealing ulcer(s), or minor tissue loss, with imaging findings of CFA occlusive disease (isolated or with additional infrainguinal lesions in the ipsilateral limb) amenable to endarterectomy of the CFA (isolated or combined with a profundoplasty or with the endarterectomy of the superficial or deep femoral artery first tract, not >1 cm long) were enrolled in the study. We excluded all patients with major tissue loss for which a contemporary infrainguinal revascularization was performed because treating the inflow disease alone would not be sufficient to heal the ischemic wound(s) owing to the presence of concomitant femoral and/or distal lesions, inadequate collateralization, or poor runoff. Descriptive demographic data, risk factors, clinical manifestations, and operative details were recorded. Primary patency (PP), assisted PP (APP), and limb salvage (LS) rates, freedom from additional proximal or distal revascularization in the ipsilateral limb, and survival were assessed using Kaplan–Meier life tables. Univariate and multivariate analyses were performed to identify which factors could influence CFA segment patency or other parameters.In all, 117 patients were enrolled and underwent 121 CFA endarterectomies, 60.3% for claudication and 39.7% for critical limb ischemia (CLI); 30 patients were excluded because they underwent a contemporary infrainguinal revascularization. All procedures were performed with patients under regional anesthesia and took an average operating time of 1.3 ± 0.7 hours. There were no perioperative deaths or major complications, but 8 (6.6%) local complications. A complete follow-up (mean 4.2 years) was obtained in 111 patients (115 limbs). The 7-year PP, APP, and LS rates were 96%, 100%, and 100%, respectively; the 7-year rates of freedom from further revascularization and survival were 79% and 80%, respectively.Operative endarterectomy in patients with claudication or CLI for occlusive CFA disease proved safe, effective, and durable, and should provide a baseline for comparison with endovascular treatment. Proponents of endovascular procedures as a routine alternative treatment option should bear this in mind.

Inflow Atherosclerotic Disease Localized to the Common Femoral Artery: Treatment and Outcome

Severe occlusive disease of the common femoral artery without significant aortoiliac disease is not common in our experience. Since 1978 we have operated upon 29 limbs in 22 patients (mean age 60) with localized common femoral artery disease. Indications for operation were claudication in 31% and impending limb loss in 69%. Operations included common femoral artery endarterectomy with patch angioplasty (19 limbs), patch angioplasty alone (two limbs), and common femoral artery endarterectomy without a patch (three limbs). Operative mortality was zero; there were nine wound complications, one patient had a myocardial infarction with early thrombosis. Symptomatic relief was obtained in 20 of 22 patients. All minor amputations healed. The mean postoperative ankle/brachial index increased to 0.67 from 0.49. Mean follow-up is 37 months (one-118 months); there have been 10 late deaths. Cumulative two and five year patency rates are 82% and 74%, limb salvage is 80% and 80%, respectively. Major amputations were required in five patients at two, two, 12, 23, and 68 months. Further inflow procedures were required in four patients: three aortobifemoral bypasses and one axillofemoral bypass. Although this disease has an uncommon inflow level, it is amenable to safe, durable, local procedures.