Common Femoral Artery Endarterectomy Research Articles

Open surgery of common femoral artery occlusive disease: a contemporary review.

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.

Tips and Tricks to Facilitate the Combined Iliofemoral Endarterectomy With Stenting for Heavily Calcified Common Femoral Artery Atherosclerosis With Involvement of the External Iliac Artery.

Management of a heavily calcified atherosclerotic occlusive disease involving the common femoral artery (CFA) and external iliac artery (EIA), poses a surgical challenge. Though the current guidelines recommend open surgical therapy for such lesions, this approach is neither easy nor represents the current real-life practice. To describe tips and tricks facilitating the hybrid technique for the management of distal iliofemoral atherosclerotic disease, where classic endarterectomy is inadequate or ill-performed. A contralateraly inserted guidewire reaches the distal iliac artery via the crossover technique and is directly retrieved from the femoral arteriotomy immediately after removal of the anterior plaque segment. The retrieved and secured guidewire enables extensive retrograde CFA endarterectomy over the wire with avusion proximally to the inguinal ligement, followed by patch arterioplasty. Externalizing the guidewire from the patch enables traction on it and facilitates advancement of the stent through tortuous or stenosed iliac vessels as well as accurate stent deployment to cover the margin of the EIA residual plaque. Moreover, this manipulation enables ipsilateral placement of a sheath and passage of a second, retrograde guidewire to perform kissing stenting in the common iliac vessels. Chronic thrombotic lesions require covered stents to avoid thrombus propagation and meticulous flushing before completion of the femoral patching. The combined iliofemoral endarterectomy with stenting does not require advanced endovascular skills and prevents complications associated with incomplete femoral endarterectomy. Extensive avulsion endarterectomy proximal to the inguinal ligament is efficiently and safely performed over a retrieved crossover guidewire, enabling precise residual stenting above the flexion site.

Endovascular Approach to Complex CTO Lesion in a Poor Surgical Candidate

Despite the various uses of endovascular and surgical techniques in management of patients with critical limb ischemia (CLI), traditional open bypass surgery with vein graft was shown to be more durable in the long term in long segment and heavily calcified lesions per the Best-CLI trial. However, patients with extensive cardiovascular risk factors and poor surgical candidates benefit from an endovascular approach. Endovascular revascularization of long segment lesions is complex and often requires the use of multiple unique techniques. Here, we present a case of a 76-year-old male with complex cardiovascular history with history of partial amputation of the right great toe and fifth toe who presented with non-healing ulcers overlying the right first and fifth distal metatarsals. A 76-year-old man with complex cardiovascular history presented with limited mobility, rest pain, and non-healing ulcers overlying the right first and fifth distal metatarsals. Bilateral common femoral artery (CFA) endarterectomy and lower left extremity angioplasty with stenting was done in the past. Doppler studies demonstrated dampened and flat pulses throughout the right lower extremity. Current computed tomography angiography (CTA) showed occlusion of the right superficial femoral artery (SFA) from the ostium to the P3 segment of the popliteal artery with significant calcification. Through ultrasound-guided left CFA access, a .035 guidewire and sheath were advanced into right distal CFA/proximal SFA and with angiogram confirming CTA results. Through the ultrasound-guided right PTA access and double flossing technique, retrograde V-18 guidewire was advanced into the antegrade Navicross catheter positioned within the right CFA. Subsequently, over the guidewire orbital atherectomy and balloon angioplasty were performed from the distal CFA to the proximal ATA region. With use of intravascular ultrasound for vessel diameter measurement, self-expanding stents were placed from the proximal SFA to the distal popliteal region. Final angiogram demonstrated an improvement of luminal diameter with less than 30% stenosis through the right lower extremity. Patient was started on Xarelto and aspirin. Multimodal endovascular technical approaches such as double-crossing flossing technique, controlled antegrade and retrograde tracking (CART) and reverse CART technique, and synapse rendezvous technique help with management of complex long segment occlusions. The case above demonstrates the use of double-crossing flossing technique in successful revascularization of a patient with end-stage CLI.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Aorto-iliac and infrainguinal artery occlusive disease: different revascularization options according to the critical limb threatening ischemia category.

Critical limb threatening-ischemia (CLTI) can be due to an extensive involvement of both the aorto-iliac (AI) and the infra-inguinal (II) districts and the efficacy of and extensive AI+II vs. only AI revascularization is still matter of debate. The aim of the present study was to evaluate the outcome in CLTI patients with concomitant AI and II peripheral artery disease (PAD) after revascularization limited to the AI or extended also to the II segment. Patients with CLTI and concomitant AI (TransAtlantic InterSociety Consensus: C-D) and II PAD (Global-Anatomic-Staging-System: II-III) from 2016 to 2021 were retrospectively evaluated. Patients were compared according to type of revascularization: limited to AI vs. AI+II. Common femoral and profunda artery endarterectomy (C/P-TEA) was considered in both groups. Perioperative mortality, limb salvage, foot healing (within 6 months after surgery), necessity of adjunctive revascularization and survival were analyzed and the follow-up performed with clinical and duplex assessment every six months. The primary endpoint was to evaluate the composite event of limb salvage, wound healing and necessity of adjunctive revascularization during follow-up in AI vs. AI+II groups, through Kaplan Meier and Cox regression analysis. Over a total of 1105 peripheral revascularizations for CLTI, 96 (8.7%) patients met the inclusion criteria for the study. AI revascularization was performed in 38 (40%) and AI+II in 58 (60%). AI and AI+II groups were similar for preoperative risk factors and extension of PAD with the exception of American Society of Anesthesiology (ASA) Classification (ASA IV: 50% vs. 25%, P=0.02, respectively). The AI group was treated with angioplasty/stenting in all cases and with C/P-TEA in 20 (52%) cases. In the AI+II group, the AI district was treated by angioplasty/stenting in 55 (95%) and by aorto-bifemoral bypass in 3 (5%) and C/P-TEA in 20 (34%). The II revascularization was performed by femoro-popliteal/tibial bypass in 27 (47%); and endovascular revascularization in 31 (53%) patients. Minor amputation rate was similar between AI and AI+II revascularization (39% vs. 48%, P=1.0); length of stay, blood transfusion units, were significantly higher in AI+II group: 7±4 days vs. 12±5 days, P=0.04 and 2±2 vs. 4±2, P=0.02. The 30-day mortality was 7% with no differences according to the type of treatment. At a mean follow-up of 28±10 months, the overall limb salvage was 87±4% with similar results in AI vs. AI+II revascularization (95±5% vs. 86±6%; P=0.56). AI had a higher necessity of adjunctive revascularization and lower wound healing compared to AI+II (18±9% vs. 0%, P=0.02; 72% vs. 100%, P=0.001, respectively). AI+II was associated with a better primary endpoint compared to AI (87±5% vs. 53±9%, P=0.01), and it was confirmed in Rutherford 5 and 6 patients (100% vs. 54±14%, P=0.01; 78±9 vs. 50±13%, P=0.04), and no differences in Rutherford 4 (100% vs. 100%). Cox regression analysis confirmed AI+II as an independent protector for the primary outcome (hazard ratio: 0.23, 95% confidence interval 0.08-0.71). CLTI with extensive PAD disease can be treated with limited AI revascularization in Rutherford 4 patients however in case of category 5 or 6 an extensive revascularization (AI+II) should be considered.

Feasibility of patchless proximal profundoplasty and common femoral endarterectomy.

Typical repair of common femoral artery (CFA) occlusive disease involves surgical endarterectomy followed by patch closure; however, prosthetic materials may become infected. In addition, in our institution, we have experienced an increased incidence of severe patch-related restenosis. We describe a technique for CFA endarterectomy and patchless proximal profundoplasty, and evaluate its feasibility. We performed a single-centre retrospective cohort study of patients who, between July 1, 2020, and June 30, 2021, underwent a procedure that consisted of transection of the superficial femoral artery (SFA) off the femoral bifurcation in a bevelled manner, eversion endarterectomy of the SFA, remote-type endarterectomy of the CFA, direct visualization of the end point in the profunda femoris artery (PFA) with a longitudinal arteriotomy extension if needed and reimplantation of the SFA "hood" as a patch. We collected clinical information and outcomes from the patients' charts. Ten patients who underwent a patchless profundoplasty procedure during the study period were identified. Indications for repair included tissue loss (3 patients), rest pain (2 patients), claudication (3 patients) and establishing access for other procedures (2 patients). Profunda femoris artery arteriotomy extensions were used in 5 cases. Six cases included simultaneous iliac or infrainguinal revascularization. All cases were technically successful. There was 1 intraoperative complication of remote tibial balloon angioplasty tear. The mean follow-up time was 199 (range 29-381) days. There were no surgical site infections. All patients were asymptomatic, with patent CFAs, at last follow-up. There was 1 case of surgical site restenosis and 1 reintervention for remote stenosis. The average increase in ankle and toe brachial indices was 44% and 75%, respectively. One patient was readmitted for gastrointestinal bleeding. One patient died from an acute myocardial infarction, on postoperative day 34. The patchless profundoplasty technique is feasible and results in autologous anatomic repair of CFA disease without the need for vein, and allows direct visualization and tacking sutures of the proximal PFA. This technique may replace the ubiquitous vascular procedure of patch arterioplasty of the CFA, depending on the anatomic configuration.

Eligibility of Common Femoral Artery Atherosclerotic Disease for Endovascular Treatment – the CONFESS Study

Advances in endovascular technologies have allowed the treatment of common femoral artery (CFA) steno-occlusive disease by minimally invasive means; however, the proportion of lesions treated with common femoral artery endarterectomy (CFAE) which would be amenable to endovascular treatment is unknown. This observational study aimed to describe the morphology and composition of CFA lesions treated with CFAE and report the proportion that would be amenable to endovascular treatment with modern technologies.

Common femoral artery endarterectomy by eversion versus prosthetic patch angioplasty: a propensity-matched study.

Endarterectomy with prosthetic patch angioplasty is the preferred treatment for common femoral artery occlusive disease. Eversion endarterectomy was described as a promising alternative. the aim of this study was to compare the eversion endarterectomy and patch angioplasty outcomes for patients with de novo femoral bifurcation atherosclerotic lesions. this study was a single-center, retrospective analysis of prospectively collected registry data, non-randomized cohort. Patients treated by eversion endarterectomy and patch angioplasty for de novo femoral bifurcation atheromatous lesions were evaluated. Between January 2016 and June 2019, all patients with de novo femoral bifurcation atheromatous lesions with a stenosis ≥70% were included in a prospective single-center database. Patients undergoing eversion endarterectomy and patch angioplasty were propensity-matched by age, sex, preexisting comorbidities, and lesion characteristics. There were 51 eversion endarterectomy and 137 patch angioplasty cases. One-to-one propensity matching yielded 51 pairs of patients. In the matched population, intermittent claudication was the most common clinical presentation (68% for both groups; P=0.83). There was no difference in femoral bifurcation lesion types between the two groups (P=0.11). Univariate analysis found no significant difference between the groups in terms of 30-d morbidity and mortality (10% and 16%; P=0.55). At 24 months, there was no significant difference in primary sustained clinical improvement (72% and 86%; P=0.22), primary patency rate (90% and 98%; P=0.48), and freedom from target lesion revascularization (100% and 98%; P=0.31) between the groups. This propensity-score analysis did not show any advantage for the EE. The EPPA should be the first line treatment of de novo femoral tripod occlusive disease. Results show that patch angioplasty treatment for de novo femoral bifurcation atheromatous could improve the daily practice with a good clinical improvement and primary patency.

Perception and acceptability of open versus endovascular treatment of common femoral artery disease: barriers and facilitators for randomised controlled trials

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.

Outcomes of Femoral Endarterectomy with Superficial Tributary Vein Patch Angioplasty

Surgical endarterectomy is still considered the gold standard for the treatment of common femoral artery (CFA) occlusive disease. The present study evaluated the outcomes of CFA endarterectomy with patch angioplasty using the superficial tributary vein (STV) of the great saphenous vein. This was a single-center, retrospective study. We reviewed our institutional data of consecutive patients who received elective CFA endarterectomy between January 2014 and December2021. During the study period, CFA endarterectomy with STV patch angioplasty was performed in 49 limbs in 42 patients, including 33 limbs (67.3%) treated by hybrid procedure combining CFA endarterectomy with endovascular treatment. Technical success was achieved in 100% of subjects. The median ankle brachial pressure index improved from 0.57 (0.43-0.67) preoperatively to 0.96 (0.77-0.99) postoperatively (P<0.001). The 30-day mortality rate was 2.0% (n=1). The overall 30-day complication rate was 6.1% (n=3) and the local complication rate was 2.0% (n=1). No aneurysmal dilatation or rupture of an STV patch was observed at a median follow-up of 22months. The 1-year and 2-year primary patency rates were 97.4% and 97.4%, respectively. The efficacy and patency of CFA endarterectomy with STV patch angioplasty were similar to those of conventional CFA endarterectomy. STV patch angioplasty is a durable procedure and may improve the outcomes of CFA endarterectomy through a reduction in the risk of postoperative local complications by avoiding the use of a prosthetic patch and by preserving the main great saphenous vein.

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

Advances in endovascular technologies have allowed the treatment of common femoral artery (CFA) steno-occlusive disease by minimally invasive means; however, the proportion of lesions treated with common femoral artery endarterectomy (CFAE) which would be amenable to endovascular treatment is unknown. This observational study aimed to describe the morphology and composition of CFA lesions treated with CFAE and report the proportion that would be amenable to endovascular treatment with modern technologies. Patients presenting with symptomatic peripheral artery disease who underwent CFAE from January 2014 to December 2018 in two tertiary NHS hospitals were included. Extensive data relating to patient demographics, risk factors, clinical outcomes, as well as anatomical and morphological characteristics of the CFA atherosclerotic lesions, were collected which included detailed plaque analysis using 3D reconstruction of pre-operative computed tomography angiograms. CFA lesions were considered suitable for endovascular treatment if presented with patent iliac inflow, at least one patent outflow vessel (superficial femoral artery [SFA] or profunda femoral artery [PFA]), and stenotic rather than occluded CFA. A total of 829 CFAs in 737 consecutive patients who underwent CFAE were included (mean age 71 ± 10 years; 526 males, 71%); 451 (62%) presented with chronic limb threatening ischaemia. Overall, 35% of CFAs had a localised lesion (no bifurcation disease) that could possibly be treated endovascularly. In total, 376 (45%) target vessels did not feature severe calcium load, with a patent CFA, PFA, and proximal SFA and therefore would have been amenable to endovascular treatment; while 271 CFAs (33%) featured a significant calcium load which would have potentially required stenting. A significant proportion of patients with atherosclerotic CFA lesions who undergo surgery could potentially be candidates for endovascular treatment. A randomised trial comparing CFAE and new endovascular techniques in this clinical context is required.

Open Proximal Endarterectomy with Retrograde Access and Stenting: A Novel Technique for Lower Extremity Revascularization.

Treatment of chronic limb threatening ischemia (CLTI) poses a significant clinical challenge despite recent medical advancements. Chronic total occlusion (CTO) lesions make endovascular approaches to CLTI particularly challenging. Open proximal exposure with retrograde access and stenting (OPERAS) aims to solve this challenge through retrograde subintimal crossing of a CTO with direct visualization of proximal re-entry into the true lumen. We describe this novel technique and present its efficacy in eight patients. We conducted a retrospective case series at a single tertiary academic center. Data for patients who received OPERAS intervention included demographics, peri-operative details, and follow-up information. Statistical analysis was performed on length of stay, major post-operative complications, further intervention, clinical progression at 1year, and amputation-free survival at 1year. Immediate technical failure (ITF) and limb-based patency (LBP) at 1year were calculated. Nine limbs underwent OPERAS between January 2019 and March 2020. Inflow was achieved with common femoral artery endarterectomy. All limbs underwent balloon angioplasty and stenting of the SFA, and seven underwent the same procedure in the popliteal artery. ITF was 0% for all nine cases. There were no major post-operative complications, and ankle-brachial index significantly improved pre-and post-operatively (P < .001). Eight limbs (88.9%) sustained amputation-free survival at 1year, and overall LBP was 67% at 1year. Our study presents a hybrid revascularization option to address severe, anatomically complex limbs (GLASS III) that lack a single autogenous conduit for open surgical revascularization. OPERAS addresses a main point of technical failure of subintimal techniques by directly visualizing the wire in the true lumen. Our data suggest that OPERAS can be effective to: (1) improve technical success of luminal re-entry following a subintimal approach; (2) address inflow concurrently with severe femoropopliteal disease; and (3) can be utilized when distal tissue loss is involved.

Five-Year Experience With the Zenith Fenestrated Endovascular Graft for Treatment of Juxtarenal Abdominal Aortic Aneurysms at a Medium Volume Center

The use of fenestrated endovascular aortic repair (FEVAR) to treat abdominal aortic aneurysms involving the visceral arteries has increased worldwide with excellent results. The aim of this study was to evaluate the safety and effectiveness of the Zenith fenestrated endovascular graft (Cook Medical, Bloomington, IN) for the treatment of juxtarenal abdominal aortic aneurysms (AAAs) at a medium volume center. We performed a 5-year (2015-2020) retrospective analysis of all patients who had presented to our institution with juxtarenal AAAs and undergone FEVAR. Custom-made fenestrated stent grafts were designed with one to three fenestrations after analysis of computed tomography data sets. Renal alignment was performed with balloon-expandable stents. Follow-up included clinical examination, laboratory studies, mesenteric-renal duplex ultrasound, abdominal radiography, and computed tomography at hospital discharge, at 1, 6, and 12 months, and annually thereafter for ≤5 years. A total of 25 patients with juxtarenal AAAs had undergone FEVAR during the study period and were included in our analysis. Of the 25 patients, 18 were men and 7 were women, with a mean age of 71 ± 10 years. The mean aneurysm diameter was 60 ± 5 mm. A total of 53 visceral arteries required incorporation with fenestrations. Of these, 51 (96%) fenestrations were aligned by stents. Technical success was 100%. One intraoperative complication occurred. The patient developed bilateral common femoral artery plaque dissection and required common femoral artery endarterectomy. The mean length of hospital stay was 2.8 ± 1.5 days. No aneurysm ruptures or conversions were noted during a mean follow-up of 41 ± 15 months (range, 6-67 months). Of a total of 50 renal arteries targeted by fenestration, one renal artery occlusion (2%) and five cases of stenosis (10%) developed. Five patients (20%) required secondary interventions for renal artery stenosis or occlusion. One type I endoleak developed in 2 patients and one type II endoleak developed in 11 patients. One patient with a type II endoleak had experienced an increase in sac size at 1 year and underwent inferior mesenteric artery ligation. None of the patients died during the follow-up period. Our study has demonstrated that endovascular repair of juxtarenal AAAs with the Zenith fenestrated AAA stent graft at a medium volume center is safe and effective. Mortality and morbidity are low for properly selected patients treated at centers with experience in these procedures.

Editor's Choice – Hybrid vs. Open Surgical Reconstruction for Iliofemoral Occlusive Disease: A Prospective Randomised Trial

The aim of this non-inferiority randomised trial was to compare the short and midterm safety and efficacy of hybrid repair (HR) and open reconstruction (OR) for patients with co-existing iliac and common femoral artery (CFA) occlusive disease. The study was registered on the ClinicalTrials.gov register (identifier: NCT02580084). From 2015 to 2017, eligible patients presenting with combined iliac and CFA occlusive disease were randomised to either HR or OR. HR group patients underwent recanalisation and stenting of iliac arteries combined with CFA endarterectomy and patch angioplasty. The OR group underwent aortofemoral bypass with simultaneous CFA endarterectomy. Short (30 day) and midterm (36 month) outcomes including morbidity, mortality, and patency rates were compared between groups. Of 427 patients assessed, 202 were randomised (102 HR and 100 OR). The average hospital length of stay was shorter in the HR group (8.2 ± 4.2 days HR group vs. 15.7 ± 6.9 days OR group, p < .001); the 30 day peri-operative morbidity rate was 8.8% in the HR group vs. 21% in the OR group (p= .030). There was no significant difference in the 36 month mortality rate (p= .16). The cumulative primary patency rates were 93% (HR) vs. 93% (OR) at 12 months and 91% (HR) vs. 89% (OR) at 36 months (p= .38). The limb salvage rates were 99% (HR) vs. 99% (OR) at 12 months and 98% (HR) vs. 97% (OR) at 36 months (p= .49). The results of this first non-inferiority randomised study support the safety and midterm efficacy of hybrid procedures for patients with iliofemoral peripheral arterial disease. HR patients had a shorter length of stay with reduced peri-operative morbidity and similar medium term patency rates.

Early and midterm outcomes of hybrid first line treatment in patients with chronic limb threatening ischemia

The aim of the study was to evaluate the outcome of first line hybrid treatment in patients with chronic limb threatening ischemia (CLTI) and to evaluate possible predictors of primary patency (PP) loss and limb clinical improvement (LCI). This was a retrospective non-randomized study. All patients underwent one-stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularization procedure. Demographic, clinical, and lesion characteristics for each patient were reported. Primary patency analysis was performed using Kaplan-Meier life tables, and univariate and multivariate analysis was used to assess possible predictors of PP loss and clinical improvement. Complete data were obtained from 132 patients. Patients were divided into two groups according to their Rutherford's category (RC), group 1 (Rutherford 4) and group 2 (Rutherford 5 and 6). Technical success was 98%. The overall surgical peri-operative complication rate was 8%. At a mean follow-up of 32 ± 23 months, the rate of major adverse limb events (MALE) was 30%; only the rate of major amputation between two groups was significant statistically different (p = .006). Group 1 had significantly lower amputation rate at 36 months (p = .01). The presence of high iliac peripheral artery calcium scoring system (PACCS) grade (HR 9.43, 95% CI 2.40-36.9, p = .001), the poor run-off of leg vessels (HR 0.15, 95% CI 0.02-0.92, p = .04), and undergoing CFA endarterectomy combined with outflow endovascular revascularization procedure (HR 4.25, 95% CI 1.07-16.89, p = .04) were independent predictors of PP loss, while severe iliac artery stenosis (OR 0.09, 95% CI 0.02-0.32, p = <.001) and the presence of pre-operative patent leg vessels (OR 8.03, 95% CI 2015-29.95, p = .002) were the significant independent predictors of LCI. The use of hybrid first line approach in patients with CLTI is a safe and feasible technique. From the analysis of the current study, it is clear that any effort should be made to achieve as many patency leg vessels as possible in order to obtain better and longer lasting clinical outcomes.

Determinants of Success and Early Complications in Common Femoral Artery Endarterectomy: A Retrospective Study

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.

Short and long-term outcome after common femoral artery hybrid procedure in patients with intermittent claudication and chronic limb threatening ischemia.

Background: This study aimed to evaluate the differences between the outcomes of patients with intermittent claudication (IC) and chronic limb threatening ischemia (CLTI) who underwent a hybrid procedure comprising common femoral artery endarterectomy and endovascular therapy. Patients and methods: This was a retrospective single-center study of all patients with peripheral arterial occlusive disease (PAD) who underwent the hybrid procedure between March 2007 and August 2018. The primary endpoint was primary patency after 7 years. The secondary endpoints were primary-assisted patency, secondary patency, limb salvage, and survival. Results: During the follow-up period, 427 limbs in 409 patients were treated. A total of 267 and 160 patients presented with clinical signs of IC and CLTI, respectively. The 30-day mortality was 1.4% (IC: 0% vs. CLTI: 3.8%, p=0.001). The overall 30-day major amputation rate was 1.6% (IC: 0% vs. CLTI: 4.4, p=0.001). The rates of primary and secondary patency after 7 years were 63% and 94%, respectively, in the IC group and 57% and 88%, respectively, in the CLTI group; the difference was not significant. Limb salvage (94% vs. 82%, p=0.000) and survival (58% vs. 29%, p=0.000) were significantly higher in the IC group. In a multivariate analysis, CLTI was the only risk factor for major amputation. CLTI and single vessel run-off were risk factors for death. Statin therapy was a protective factor. Conclusions: The hybrid procedure provides excellent results as a treatment option for multilevel lesions in patients with PAD. However, patients with CLTI had a shorter long-term survival and lower limb salvage rate.

The Use of a Vascular Surgery Operative Cost Sheet to Increase Surgeon Financial Awareness and Decrease Operative Cost

Operative expenses compose one-third of the rising health care costs in the United States. Therefore, novel strategies for mitigating cost in the vascular surgery space are warranted. Our institution implemented a cost reduction strategy in 2017 by simply showing surgeons the costs of their implants and disposable supplies at the end of each case in order to increase surgeon financial awareness and reduce costs. We performed a retrospective analysis of recorded supply and implant costs for vascular procedures from 2015 to 2018 at a single institution. Total operative cost was defined as the accumulated implant and supply cost during a procedure. We assessed total implant and disposable supply cost, supply cost alone, and cost per time. Cost was analyzed over two periods: the 24 months prior (PRE) to the tool implementation and 24 months following (POST) with a 1-month washout. Medians and interquartile ranges were calculated for each parameter and compared using the Mann-Whitney U test. We analyzed a total of 1372 procedures performed over the time period studied. Total supply and implant cost (–17.5%; P = .008), supply cost (–1.99%; P = .049) and cost per minute (–28.24%; P = .015) all saw significant reductions across the composite of open procedures from the PRE to POST time point (Table). Largest supply cost reductions were seen in common femoral artery endarterectomy (–42%; P < .001). The total operative cost/time was most significantly reduced for carotid endarterectomy (–8.89%; P = .001), abdominal aortic aneurysm repair (–16.21; P = .019), carotid-subclavian bypass (–9.94%; P = .032), and common femoral endarterectomy (–41.16%; P = .06), with nonsignificant cost reductions in arteriovenous grafting and rib resection. Relative price increases of 31%, 8%, and 3% were calculated for temporal artery biopsy, vein transposition, and distal bypass, respectively. The composite of all endovascular procedures saw large implant cost increases with minimal change in supply cost. We demonstrate that a low-cost, highly implemenTable cost sheet is effective at reducing cost in vascular surgery. Further investigations should assess how and why surgeons choose supplies and implants in order to target further intraoperative cost savings.TableCost trends before and after implementation of a cost sheet across multiple vascular surgery proceduresProcedureTotal operative cost (supply + implant), $Supply cost, $Total cost/time (supply + implant), $/minutePREPOST% ΔP valuePREPOST% ΔP valuePREPOST% ΔP valueCarotid endarterectomy504.3 (411.5-664)452.6 (409.5-525.7)–10.25.012250.3 (238.5-277)249.1 (235-276.1)–0.45.35344.86 (4.05-6.09)4.43 (3.77-5.25)–8.89.001AAA repair1686 (1268-2041)1399 (1257-1717)–17.01.037542.5 (432-602.5)536.8 (456.6-621.8)–1.052.81857.59 (5.67-9.49)6.36 (1.65-8.13)–16.21.019Carotid-subclavian bypass681 (609.1-805.4)682.6 (641-771.6)0.23.953272.3 (245.8-385.7)259.9 (245.1-290)–4.54.36155.49 (4.52-6.36)4.85 (1.39-5.76)–9.94.032Common femoral endarterectomy3102 (1107-5232)971.3 (532.5-4309)–68.69.0107662.4 (441.3-886.1)382.8 (237.8-566.8)–42.21<.000114.35 (6.32-14.35)8.45 (3.81-8.45)–41.16.061Arteriovenous graft181.8 (130.8-189.2)183.3 (123.8-223.1)0.822.5425113.8 (108.3-132.4)112.5 (106.7-125.9)1.0865.54112.07 (1.39-10.57)1.70 (1.48-2.67)–17.65.14Rib resection119.7 (115.8-124.6)116.6 (112.2-149.2)–2.577.8662120.3 (117.8-123)114.6 (109.7-138.3)–4.738.05621.46 (1.25-2.06)1.39 (1.02-2.11)–4.46.56Temporal artery biopsy45.25 ( 34.41-73.4)90.26 (47.84-121.4)99.49.000345.25 (34.41-73.4)90.55 (48.17-121.4)100.01.00041.38 (0.79-1.79)1.81 (1.25-3.05)30.92.0099Upper extremity vein transposition181.9 (125.1-249)187.7 (132.2-269.2)3.16.5116127.2 (113-145.7)114.9 (101.3-121.1)–9.669.00081.89 (1.02-2.84)2.05 (1.39-2.56)8.68.53Distal bypass831.7 (491.8-2315)767.6 (480-2987)–7.69.8428308.8 (244.9-382.6)377.9 (242.4-572)22.36.08172.64 (1.87-7.98)2.72 (1.59-8.29)3.26.94All endovascular (EVAR + TEVAR)17653 (12890-24376)22524 (15366-29092)27.59.00022031 (1581-2588)2022 (1559-2597)0.437.8103180.3 (11.4-262.1)163.2 (97.84-271.4)–9.48.6396All open549 (275.1-1115)452.7 (209.3-782.4)–17.54.0078250.3 (141.1-411.1)245.3 (121.5-343.2)1.99.04935.237 (2.039-11.03)3.758 (1.86-7.241)–28.24.015AAA, Abdominal aortic aneurysm; EVAR, endovascular aneurysm repair; POST, the 24 months following tool implementation; PRE, The 24 months prior to the tool implementation; TEVAR, thoracic endovascular aneurysm repair.Values are median (interquartile range). Open table in a new tab

Hybrid Technique: Common Femoral Artery Endarterectomy and Endovascular Therapy in Critical Lower Limb Ischemia

Introduction: Multilevel arterial occlusive disease in patients with chronic limb threatening ischemia (CLTI) represent a major revascularisation challenge to vascular surgeons. The goal of treatment is a single intervention procedure that results in an excellent technical success without associated complications or the need for further interventions. Methods: Prospective case series study including (30) patients complaining from critical lower limb ischemia (rest pain or tissue loss) and has CFA lesionwith proximal or distal lesions. All patients undergoing common femoral Endarterectomy and endovascular therapy to proximal or distal lesions between May 2018 and December 2020. The study was conducted at the department of vascular and endovascular surgery in Mansoura university hospitals Results: Femoral Endarterectomy was performed in all cases in the current cohort with combined iliac and SFA revascularization in 27% of patients and with separate iliac in 10% and outflow in 63% of cases (SFA 33% and tibial 30%). This study reported a 100% technical success and 96% hemodynamic and clinical success in the current series. And the 2-year patency was 88% Conclusion CFE should remain the treatment of first choice of CFA occlusive disease as it is safe, effective, and durable procedure for common femoral artery disease, and the simultaneous hybrid CFA endarterectomy and endovascular therapy for multilevel occlusive artery disease can provide an immediate satisfactory results, durable midterm patency, and also less invasive therapeutic option in high-risk patients.

Outcomes after Standalone Use of Gore Excluder Iliac Branch Endoprosthesis for Endovascular Repair of Isolated Iliac Artery Aneurysms

The aim of our study was to describe outcomes of stand-alone use (i.e., without concomitant implantation of an aortic stent graft) of the Gore Excluder iliac branch endoprosthesis (IBE) for elective endovascular repair of isolated iliac artery aneurysms. We evaluated all consecutive patients electively treated for isolated iliac artery aneurysms using standalone Gore Excluder IBE (January 2014-December 2018). Early (i.e., 30-day) endpoints were technical success, mortality, major adverse events (MAEs), and major access-site complications. Late endpoints were survival, freedom from aortic-related mortality (ARM), internal iliac artery (IIA) primary patency, IIA branch instability, graft-related adverse events (GRAEs), secondary interventions, endoleaks (ELs), aneurysm sac behavior, and new-onset buttock claudication (BC). A total of 11 consecutive patients (10 men; median age 75years) were included. The technical success rate was 100%. At 30days, mortality, MAEs, and major access-site complications were all 0%. Survival and freedom from ARM were 91% and 100%, respectively; only one nonaortic related death was recorded during follow-up. At a median follow-up of 14months, IIA primary patency, IIA branch instability, and GRAEs were 100%, 0%, and 0%, respectively. No instances of graft migration ≥10mm were detected. No graft-related secondary interventions were recorded, and 2 patients required a procedure-related secondary intervention 3months after the index procedure (1 common femoral artery endarterectomy and 1 external iliac artery stenting). Although new-onset type 1 or type 3 ELs were never noted, one patient developed a new-onset type 2 EL. Aneurysm sac regression ≥5mm was noted in 6 patients (55%), whereas in the remaining ones, the sac size was stable. No instances of new-onset BC were noted. Use of standalone Gore Excluder IBE for elective endovascular repair of isolated iliac artery aneurysms is a safe, feasible, and effective treatment option. These results may support use of the technique as an effective means of endovascular reconstruction in patients with suitable anatomy.

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

To assess mid term outcomes of common femoral endarterectomy combined with an inflow and outflow endovascular revascularisation procedure in patients with chronic limb threatening ischaemia (CLTI). This was a prospective study. All patients who, for the first time, underwent planned one stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularisation procedure to achieve limb salvage in patients with CLTI due to multilevel disease were included between January 2015 and May 2017. Demographics, and clinical and lesion characteristics for each patient were reported. The primary outcome was primary patency. Secondary outcomes were technical success, peri-operative morbidity and mortality, assisted primary patency, secondary patency, clinically driven target lesion revascularisation and amputation free survival. Three groups were created according to the endovascular treatment zone: group 1 (inflow, n=60); group 2 (outflow, n=46); and group 3 (combined inflow and outflow, n=53). CFA endarterectomy was a fixed step in all cases. The overall technical success was 98%. The peri-operative complication rate was 14% and the mortality rate was 2%. Patients in group 3 demonstrated a significantly lower primary patency rate (53.9%±7.1%; p<.001) at 24 months but improved secondary patency rate of (94.0%±3.4%). Based on the outcomes of the Cox regression multivariable analysis, lesion length (hazard ratio [HR] 1.10, 95% confidence interval [CI] 1.06-1.14; p<.001), chronic total occlusion (CTO) (HR 0.50, 95% CI 0.25-0.98; p=.046), peripheral artery calcium scoring system (PACSS) grade 4 (HR 2.44, 95% CI 1.27-4.68; p=.008), incomplete revascularisation (HR 3.32, 95% CI 1.64-6.73; p=.001), and dyslipidaemia (HR 0.50, 95% CI 0.27-0.93; p=.031) were the only significant independent predictors of loss of primary patency. Common femoral endarterectomy combined with an inflow and outflow endovascular revascularisation procedure in patients with CLTI is safe, with acceptable patency rates, despite the need for secondary interventions. Dyslipidaemia, lesion length, CTO, PACSS grade 4, and incomplete revascularisation are independent predictors of primary patency loss. The current study analysis supports the recommendation to stage the procedure based on patient risk and degree of limb threat.