Endarterectomy of the superficial femoral artery

Semiclosed endarterectomy of the SFA belongs in the armamentarium of the vascular surgeon. New technology offers the possibility of performing this less invasive operation so that only a single incision is needed to obtain access to the artery and perform remote disobliteration. Strong indications show that the anticipated restenosis of long, segmental, closed endarterectomies can be reduced remarkably by expanded PTFE endolining.

Development and application of modern devices in vascular surgery including comment on modern antithrombotic and lytic drug therapy

Since modern vascular surgery started with the discovery of heparin and the development of modern vascular grafts including autogenous saphenous vein, the speciality has been technologically driven. At the outset, vascular surgery depended almost entirely on the development of specialized clamps, instruments, and tools to permit decisive attack on the problems of occlusion. No less important was the development of insight into the basis of atherosclerosis, the discovery that atherogenesis with thrombosis is electrochemically identical to corrosion in pipes and therefore subject to chemical forces, which have not yet been delineated, as well as mechanical forces which have been delineated and permit one to attack the atheroma directly. Thus, classic replumbing techniques including bypass and endarterectomy have long been a part of the fundamental firmament of vascular surgery. Most recently, modern techniques in cleaning out blood vessels, removing occlusive processes, and modern thrombus-dissolving enzymes have all come to the forefront. Frequently multiple techniques are used simultaneously. This article is an attempt to summarize various aspects of this activity and describe several of the patents which have been seminal in the ultimate application of the techniques in both experimental animals and man. This should be the first of a series of efforts to summarize this area. The process of change has never been more kinetic than now.

Long-term clinical follow-up of patients treated with the coronary rotablator: a single-center experience

The acute angiographic and long-term clinical outcomes of a consecutive series of patients treated with the coronary rotablator at a single center are described. The patient population was a high-risk population, with significant instances of unstable angina or acute myocardial infarctions (MI) on presentation (75.5%), three-vessel coronary artery disease (27.5%), congestive heart failure (23.8%), and diabetes (39%). The coronary anatomy was also complex, with 79.3% of lesions treated being National Heart Lung and Blood Institute (NHLBI) class B or C. The maximum burr:artery ratio averaged 0.79+/-0.11. The maximum balloon:artery ratio averaged 1.19+/-0.17. Acute procedural success was 90%. The reference vessel diameter was 2.72 mm +/-0.54 mm. The average minimum luminal diameter (MLD) preprocedure was 0.87+/-0.31 mm. The average MLD postprocedure was 2.01+/-0.54 mm. The acute gain averaged 1.14+/-0.51 mm. Urgent coronary artery bypass grafting was required in 1% of patients. Subendocardial infarctions occurred in 8.5% of patients, and abrupt closure postprocedure while in hospital occurred in 1% of patients. Reinterventions or coronary artery bypass grafting (CABG) in hospital occurred in only 3.5% of patients; 96% of patients were available for a long-term clinical follow-up. Repeat coronary interventions for target lesion revascularizations were required in 17.4% of patients, coronary artery bypass grafting for target lesion revascularization was necessary in 9.5% of patients, and the combined target lesion revascularization rate was 25.3% at 1 year. Subsequent Q-wave myocardial infarctions or cardiac death occurred in 5.7% of patients at 1 year. Event-free survival was 75.1% at 6 months and 69.9% at 1 year. The strongest predictor of subsequent target lesion revascularization was lesion length (P=0.034) and not the postprocedure MLD (P=0.41). Most major adverse clinical events occurred within the first 4 months and greater than 90% of all major adverse clinical events occurred within the first 6 months. The coronary rotablator was able to achieve a high degree of clinical success in a high-risk patient population with complex anatomy. Most major adverse clinical events occurred early (<6 months) and were comprised principally of target lesion revascularizations. The overall target lesion revascularization rates and combined major adverse clinical event rates are favorable, given the complex anatomy and the high proportion of diabetics, females, and multivessel disease patients treated in this series.

[Simultaneous or stepwise procedure in combined minimal invasive and conventional operation methods in vascular surgery]

Long-term results of femoral angioplasty and stenting are not as successful as open surgical procedures. Transfemoral retrograde recanalisation of the iliac vessel by semiclosed endarterectomy is a low-invasive procedure. Certainly the outcome is characterised by a number of early occlusions caused by dissections or remaining intimal flaps. Recent advances in endovascular management of occlusive disease have changed the situation. Intraoperative control of lumen by angioscopy and removal of occlusive material via TV-monitored endoscopic manipulation has induced better results of endarterectomy. In addition to this more effective recanalisation, the proximal intimal step, mostly at the level of the iliac bifurcation, is managed by intraoperative balloon dilatation and stenting. This combined approach has reduced the necessity of reoperation by about 15%. The cumulative 5-year patency rate for this combined procedure is 88%.

Complete thromboendarterectomy of the calcified ascending aorta and aortic arch

BACKGROUND

Arteriosclerotic plaques of the ascending aorta and transverse arch increase the operative risk of cardiac operations and are strong predictors for late cerebrovascular events.

METHODS

Twenty-two patients, mean age 68 +/- 6 years (range, 55 to 77 years), with grade IV + V plaques of the ascending aorta and transverse arch underwent coronary artery bypass grafting (n = 21) and aortic valve replacement (n = 8). Cerebrovascular emboli from unknown sources were found preoperatively in 8 patients (36%). All were in sinus rhythm. Complete thromboendarterectomy of the ascending aorta and transverse arch was performed during hypothermic circulatory arrest. After 21 +/- 12 months (range, 4 to 44 months), magnetic resonance imaging and transthoracic echocardiography of endarterectomized vessels was performed.

RESULTS

There was one perioperative death (4.5%), one early (4.5%), and one late (4.7%) adverse neurologic event. Follow-up examinations revealed normal diameters of the endarterectomized aorta.

CONCLUSIONS

For patients with grade IV + V plaques, thromboendarterectomy of the ascending aorta and transverse arch can be performed with an acceptable surgical risk and a low recurrence rate for cerebrovascular events. Dilatation of the endarterectomized aorta was not observed.

Remote endarterectomy in SFA occlusive disease

The authors present a new modified endarterectomy technique for the treatment of artherosclerotic occlusive disease of the superficial femoral artery (SFA). The SFA remote endarterectomy procedure can be performed through a single groin incision using a ring strip cutter and stenting the distal endpoint. Complete disobliteration of lengthy occlusions was accomplished in more than 100 cases with a cumulative 2-year primary and assisted primary patency rate of 71 and 86%. The mean length of the removed intima core was 33 (10-45) cm. The endovascular remote endarterectomy technique is explained and depicted in detail and some important questions and controversies are discussed.

Minimally invasive superficial femoral artery endarterectomy: early experience with a modified technique

OBJECTIVES

To describe our experience of a modified technique for carrying out remote endarterectomy for superficial femoral artery occlusive disease.

METHODS

A 4-French arterial dilator is inserted using a Smart needle into the popliteal artery below the occlusion. A remote endarterectomy is carried out through an arteriotomy in the proximal superficial femoral artery. The atheroma is cut distal to the lower extent of disease using a Moll ring cutter. The lower flap of atheroma is secured with an intraluminal stent inserted from the arteriotomy in the superficial femoral artery. The arteriotomy is extended into the common femoral artery and closed with a vein patch.

RESULTS

The procedure was completed in 21 of 26 limbs. In 18 cases the superficial femoral artery remained patent at 30 days. Of the 21 cases all but four stayed in hospital for one night. A successful femoropopliteal bypass was carried out in the five patients in whom the procedure was not completed.

CONCLUSION

Insertion of the dilator into the popliteal artery distal to the occlusion before carrying out the remote endarterectomy has two advantages. Firstly, the stent insertion is carried out in the correct plane and prevents dissection of the distal cut atheroma when attempting to pass the guidewire from above. Secondly, the procedure can be carried out under simple image intensification without sophisticated radiological equipment. The early results are encouraging and further evaluation of the technique is justifiable.

[Pulmonary thromboendarterectomy with video-angioscopy and circulatory arrest: an alternative to cardiopulmonary transplantation and post-embolism pulmonary artery hypertension]

The best predictor of poor or suboptimum outcome from pulmonary thromboendarterectomy (PTE) is insufficient relief of obstruction, especially in the lower lobes. The aim of this study is to emphasize that the use of video-assisted angioscopy may increase the quality of PTE and thus improve outcome. PTE included a median sternotomy, intrapericardial dissection limited to the superior vena cava, institution of cardiopulmonary bypass, deep hypothermia and sequential circulatory arrest periods. PTE was always bilateral and performed through two separate arteriotomies of both main intrapericardial pulmonary arteries. A rigid 5 mm angioscope connected to a video camera was introduced through the arteriotomy into the lumen to increase the visibility and perform the video-assisted endarterectomies of all obstructed segmental branches, including normally inaccessible anterior segmental branches. Between January 1996 and December 1997, 48 patients with severe postembolic pulmonary hypertension had PTE. Patients were in New York Heart Association (NYHA) class II (n = 2), III (n = 28) or IV (n = 18) with the following hemodynamics: mean pulmonary arterial pressure (PAP) 53 +/- 13 mmHg, cardiac index 2.16 +/- 0.5 L/min/m2, pulmonary vascular resistances (PVR): 1,152 +/- 414 dyne.s-1.cm-5. Six patients died from alveolar hemorrhage (n = 1), high residual pulmonary pressure and rethrombosis (n = 4) and hypoxic cardiac arrest (n = 1). The functional outcome in surviving patients was as follows: (NYHA) class I (n = 24), II (n = 16) or III (n = 2) with improved hemodynamics: mean pulmonary arterial pressure: 30 +/- 9 mmHg, cardiac index: 2.78 +/- 0.5 L/min/m2, pulmonary vascular resistances (PVR): 484 +/- 159 dynes.s-1.cm-5. Video-assisted angioscopy allows much improved quality and degree of pulmonary endarterectomy. This expands the indications to include patients with previously inaccessible distal disease and candidates for heart-lung transplantation.

Closed superficial femoral artery endarterectomy: a 2-year follow-up

Closed superficial femoral artery endarterectomy is a minimal invasive technique. Through a single groin incision the occluded intima is remotely removed by a newly modified ring stripper. This device has a double ring which acts like remote scissors and enables the surgeon to recanalize long segmental femoral popliteal occlusive disease. The device was used in 103 limbs in 90 patients. The cumulative assisted primary and secondary patency was 86%. This technique is an alternative to bypass grafting when vein is not available.

[Mechanical endarterectomy: review of the literature and description of an original device]

The Authors, after a Literature review on endovascular invasive procedures used for inferior limbs obstructive arteriopathy, describe the use of a new device for mechanical endarterectomy. Through the latest acquired experience the importance of dissecting progressively the single layers of the atheroma plaque without arriving to a complete denudation of the arterial wall, so avoiding the risk of myointimal hyperplasia reactions, is outlined. The possibility of using endoarterial stents in case of more indaginous recanalization is also stressed.

Boundary layer infusion of nitric oxide reduces early smooth muscle cell proliferation in the endarterectomized canine artery

To evaluate the direct effect of nitric oxide (NO) on vascular smooth muscle cell (SMC) proliferation in vivo, we used an expanded polytetrafluoroethylene (ePTFE)-based local infusion device to deliver an NO donor, proline/NO (PROLI/NO), to the luminal boundary layer of endarterectomized artery and the distal anastomosis of the graft in a canine model. Once delivered to the blood, PROLI/NO releases NO by a mechanism involving pH-dependent decomposition. Six dogs underwent bilateral femoral artery endarterectomies. ePTFE infusion devices, blindly primed with PROLI/NO to one artery or proline to the contralateral vessel, were anastomosed proximal to the injured segments so that each animal served as its own control. PROLI/NO or proline was continuously delivered for 7 days from an osmotic reservoir, through the wall of the graft infusion device. Euthanasia was carried out at 7 days, and the processed specimens were blindly analyzed for SMC proliferation at both graft anastomoses and endarterectomized segments by a bromodeoxyuridine index assay. All dogs survived with no clinical side effects. In comparing the treated and control vessels, NO released from PROLI/NO significantly reduced SMC proliferation by 43% (13.24 +/- 1.24% versus 23.24 +/- 1.01%, P = 0.004) at the distal anastomoses and by 68% (10.58 +/- 1.63% versus 25.17 +/- 3.39%, P = 0.007) at endarterectomized segments. However, there was no significant difference in blood flow measurements between treated and control arteries (56.25 +/- 6.50 ml/min versus 46.50 +/- 3.20 ml/min, P = 0.094). These data demonstrate that local boundary layer infusion of NO released from PROLI/NO significantly reduces SMC proliferation in injured arteries with no effect on regional blood flow. This study suggests a new strategy to inhibit early SMC proliferation in injured arteries and probably to control intimal hyperplastic lesion formation in the manipulated vessels.

Endovascular remote endarterectomy in femoropopliteal occlusive disease: one-year clinical experience with the ring strip cutter device

OBJECTIVES

One-year clinical outcome of a new endovascular treatment for long segmental arterial occlusive disease using a ring strip cutter (RSC) to minimise surgical exposure.

DESIGN

Prospective, open study.

MATERIALS

Thirty-eight consecutive RSC procedures in 36 consecutive patients with lengthy occlusive (34) or multiple stenotic (4) femoropopliteal lesions were performed. Indications for operation were disabling claudication in 25 (66%), rest pain in 3 (8%), and gangrene in 10 (26%) patients.

METHODS

A newly developed endovascular ring strip cutter device was used to perform a remote endarterectomy through a single groin incision. Clinical data were analysed based on intention-to-treat.

RESULTS

Initial angiographic, clinical and haemodynamic success was achieved in all 38 (100%) limbs. Mean ankle-brachial index increased significantly from 0.62 +/- 0.14 to 1.02 +/- 0.14 postoperatively (p = 0.01). Four failures have occurred during follow-up. After one-year experience the cumulative (assisted) primary and secondary patency rates are 80% and 85% respectively. Duplex surveillance has detected progressive recurrent stenoses in 10 cases.

CONCLUSIONS

Remote endarterectomy of long segmental femoropopliteal occlusive disease through a single groin incision with the Ring Strip Cutter device is a safe and effective procedure. The early patency rates are good. Further long-term results are needed to evaluate this technique.

Current status of atherectomy for peripheral arterial occlusive disease

Atherectomy physically removes plaque by cutting, pulverizing, or shaving it in atherosclerotic arteries using a mechanical, catheter-deliverable endarterectomy device. Theoretically, atherectomy offers the following advantages over percutaneous transluminal angioplasty (PTA): It shows a greater immediate success rate with less dissection and acute occlusion, treats complex lesions, and reduces the restenosis rate. This article presents the unique features of four atherectomy devices designed to meet the above challenges: Simpson AtheroCath, Transluminal Extraction Catheter (TEC), Trac-Wright Catheter, and Auth Rotablator. The results, complications, and limitations reported by clinical investigators are discussed critically and realistically. A new device, the OmniCath, under investigative trial, is presented briefly. Clinical studies evaluating the Simpson AtheroCath have reported impressively high initial success rates (ranging from 82% to 100%) but disparate intermediate patency results (ranging from 35% to 84%). Complications associated with the device include hematoma, pseudoaneurysm, and distal embolization. Clinical studies show that the device is relatively ineffective for treating diffusely diseased and long-occluded lesions. Restenosis has also been a primary constraint of the Simpson device, with reported restenosis rates ranging from 11% to 55% at 6 months. The initial technical and clinical success rates reported with the TEC atherectomy device have been promising at 79% to 92%; however, short- and mid-term follow-up results have been either lacking or disappointing, with a reported patency of 67% at 6 months and 51% at 12 months. Furthermore, the problems of restenosis and reocclusion have limited its short-term benefits. The Trac-Wright catheter has demonstrated widely disparate technical success rates (from 58% to 100%) and clinical success rates (from 33% to 80%). Patency rates reported have been suboptimal, ranging from 25% to 68% at 6 months and 25% to 45% at 12 months. Furthermore, severe complications associated with the device include perforation, dissection, and embolization. Reocclusion also limits the applicability of the device. The reported immediate success rates of 72% to 94% using the Auth Rotablator are similar to those reported for other atherectomy devices. Patencies reported at 1 and 2 years are dismal, ranging from 31% to 61% and from 12% to 18%, respectively. Significant complications are associated with the device, including thrombosis, arterial spasm, hemoglobinuria, hematoma, and embolization. Contrary to previous studies and expectations, perforations and dissections have been encountered by some investigators. Late restenosis and reocclusion are also significant limiting factors of the Auth Rotablator. Atherectomy currently has limited applications for treatment of peripheral arterial occlusive disease. The intermediate- and long-term results obtained with the atherectomy devices are worse than those reported for PTA. Furthermore, all of the atherectomy devices have failed to reduce the restenosis and reocclusion rates from those reported for PTA. The problem of restenosis, reocclusion, and other complications must be solved before atherectomy can be used generally as an alternative to vascular reconstruction procedures such as PTA.

[Angioscopy as intraoperative outcome control after reconstructive surgery of the renal arteries: presentation of a new method]

Main reasons for obstruction of renal arteries are atherosclerosis and fibromuscular dysplasia. In our clinic transaortic renal endarterectomy and interposition of a vein segment are preferred for arterial reconstruction. The surveillance of the distal intimal ridge after blind transaortic endarterectomy is still an unsolved problem, and the distal anastomosis of a vein graft must be checked, as it is performed under difficult conditions, if the suture is done in situ. We introduce angioscopy as a means of intraoperative surveillance.

Aortofemoral graft occlusion: strategy and timing of reoperation

The authors' experience with 46 patients treated over 8.5 years was reviewed to determine the optimal secondary revascularization procedure after occlusion of a unilateral aortobifemoral graft limb. A total of 64 procedures was performed on these patients to restore and maintain graft patency. Repetitive operations for reocclusion were needed in 14 patients (30%). Transcatheter thrombolytic therapy was used in 14 patients, four as sole therapy and 10 in conjunction with operation. The mean time from aortofemoral grafting to presentation with graft limb occlusion was 59.4 months. Rest pain or severe ischemia was present in 85%, and severe claudication in the remainder. Some 78% had urgent operation after diagnostic angiography and catheter-directed thrombolytic therapy was attempted in 22%. The etiology of graft thrombosis was outflow obstruction in 78.2% of cases. Inflow was obtained by surgical thrombectomy in 35 and by lytic therapy in 13. Extra-anatomic inflow was used in 11 and intra-abdominal thrombectomy or redo aortofemoral grafting in five. Outflow procedures, mainly profundaplasty, were performed in all but five cases (four urokinase and one surgical). Infrainguinal bypass was needed in 10 cases in addition to the groin reconstruction. Catheter-directed thrombolysis was successful in 13 of 14 instances; however, in nine of these residual stenosis was disclosed in the outflow requiring surgical repair. Ultimately, 12 of 14 cases treated with thrombolysis required surgical intervention. Cumulative patency for all procedures was 68%. Complications were seen in 14% of cases. Operative mortality was 5%, and limb salvage was obtained in 85%.(ABSTRACT TRUNCATED AT 250 WORDS)

Infrainguinal atherectomy using the transluminal endarterectomy catheter: patency rates and clinical success for 144 procedures

PURPOSE

To determine if atherectomy using the transluminal endarterectomy catheter (TEC) is an effective endoluminal therapy for infrainguinal occlusive disease.

METHODS

Three surgeons used the TEC for 144 infrainguinal atherectomy procedures in 133 patients. The indications were severe claudication in 83, critical ischemia in 56, and graft stenosis in 5 limbs. The pathology was stenosis in 36 and occlusion in 105 limbs. Balloon dilation was also performed in 109 and stenting in 17 limbs.

RESULTS

There was initial technical and anatomic success in 124 (86%) procedures. There were 67 technically successful procedures at mean follow-up of 19 months, although 3 of these limbs with gangrene and extensive distal disease required major amputation. There were 26 failures due to stenosis leading to further intervention and 51 due to occlusion. Twenty of these cases were managed conservatively, 21 were treated with repeat endovascular intervention, 31 with bypass grafting, and 5 with amputation. Repeat intervention in 52 limbs resulted in 36 with patent arteries, 10 that are occluded, and 6 that required amputation. Thirteen of the 14 amputations were for limbs with critical ischemia, but 1 was in a patient with claudication. Life-table analysis showed that the primary patency rate was 51%, the assisted primary patency rate was 61%, and the secondary patency rate was 75% at 15 months. The clinical success rate was 49%, and the salvage rate for limbs with critical ischemia was 78% at 12 months. Univariate log-rank testing showing no significant differences according to the clinical presentation of pathology, but results were worse for lesions > 5 cm long due to more frequent immediate failures. However, multivariate Cox regression analysis showed that results were significantly worse for critical ischemia than for claudication, stenosis compared to occlusions, for limbs with poor runoff, for operations performed by percutaneous rather than an open approach, and for those performed more recently.

CONCLUSIONS

TEC atherectomy may have a place in selected patients, but the optimal circumstances for its use and long-term efficacy require further study.

How to do it. A modified battery-powered toothbrush for coronary artery endarterectomy

A modified battery-powered toothbrush for performing coronary artery endarterectomy is described. The device facilitates the dissection of the atheromatous core, is safe and inexpensive.

Endarterectomy with arterial dilators: surgical technique

A simplified technique of semi-closed endarterectomy with arterial dilators that insures complete removal of intimal fragments was used by the authors. Complications, such as arterial wall penetration and residual intimal fragments, are reduced. This technique has proven useful in aortoiliac and short-segment femoral artery endarterectomy. It is also helpful for proximal anastomosis of femoral/popliteal/tibial in situ bypass where termination of saphenous vein cannot reach femoral artery.

[A new intraluminal endarterectomy instrument]

In 40 human cadaver arteries endarterectomy was performed using a new intravascular device. The system and technique are described. According to our preliminary laboratory experiences the new device proofed to be save and effective. It will allow us to approach more complex lesions not ideal for balloon angioplasty. Clinical investigations will be performed in the near future.