A minimally invasive technique in occlusive disease of the superficial femoral artery: remote endarterectomy using the MollRing Cutter

Does Conversion of Intended Remote Iliac Artery Endarterectomy Alter the Early and Long-Term Outcome?

The purpose of this study was to compare the perioperative and long-term results of initial successful remote iliac artery endarterectomies (RIAEs) with converted procedures.

From April 1994 to September 2003, 63 remote endarterectomies of the external and/or common iliac artery were planned in 62 patients (41 males, 42 procedures). The median age was 65 years (range 39–83 years), and the indication for operation was severe claudication in 37 (59%), rest pain in 16 (25%), and gangrene in 10 (16%) procedures.

Initial technical success was achieved in 56 (89%) procedures (group 1); seven conversions (group 2) were necessary. In group 1, the 5-year primary patency rate improved from 64 ± 15% to a primary assisted patency of 88 ± 9.3% after percutaneous transluminal angioplasty in 11 patients, with 7 requiring stent placement. The 5-year secondary patency rate was 94 ± 7.4%. The primary and secondary patency rates in group 2 were 86 ± 19% and 100%, respectively.

RIAE can be offered to patients with long occlusions of the iliac arteries as a first treatment option. The inherent risk of a possible conversion of an intended RIAE to a more invasive surgical procedure has no significant adverse clinical effect on the early and 5-year clinical outcomes.

Remote endarterectomy for long segment superficial femoral artery occlusive disease. A systematic review

BACKGROUND

Remote endarterectomy is a minimally invasive procedure which combines open and endovascular surgery for the treatment of long segment superficial femoral artery (SFA) occlusive disease. We conducted a systematic review of the medical literature to analyze the indications, technical limitations and the outcome of remote SFA endarterectomy (RSFAE).

METHODS

The English literature was searched using the MEDLINE electronic database up to February 2008. We considered studies comprising at least 10 patients treated with RSFAE and reporting on the primary and/or secondary patency rates. Average primary and secondary patency rates were obtained by weighting the data of each study by the number of limbs treated.

RESULTS

Our search identified 19 retrospective or prospective case series; no randomized controlled trials comparing RSFAE with another treatment modality were identified. The average technical success rate was 94% and the procedure-related complication rate was 14.7%. The weighted mean cumulative primary patency rates were 60%, 57% and 35% at 1, 2 and 5 years, respectively. The weighted mean assisted primary patency rates were 75%, 77% and 50% at 1, 2 and 5 years, respectively. The weighted mean secondary patency rates were 88% and 62% at 1 and 2 years, respectively.

CONCLUSIONS

RSFAE has acceptable short-, medium- and long-term results but patients should undergo intensive surveillance postoperatively. Randomized controlled trials are needed to assess the durability of this procedure as compared to conventional open bypass surgery.

Remote endarterectomy: Lessons learned after more than 100 cases

BACKGROUND

Bypass procedures have been the mainstay of treatment of extensive external iliac and superficial femoral artery (SFA) occlusive disease, particularly total occlusions. Since the early 1990s, reports from Europe have espoused the virtues of endarterectomy of the superficial femoral and iliac arteries from a small groin incision, but adoption in the United States has been limited. Over the past 4 years, we have explored the technical challenges and durability of this procedure and report our findings.

METHODS

Remote endarterectomy from an inguinal incision was the primary treatment option for all patients considered surgical candidates for vascular reconstruction of the external iliac and superficial femoral arteries. All data were entered into an outcomes database prospectively and reviewed retrospectively. After the procedure, duplex ultrasound surveillance was performed quarterly the first year and semi-annually thereafter.

RESULTS

Remote endarterectomy was the planned procedure in 133 patients. The mean age was 68 years, 68% were men, and 31% were diabetic. The indications for the procedure were claudication in 57% and limb salvage in 43%. In 16 patients (12%), technical issues precluded the completion of the remote endarterectomy and a bypass was performed. Successful retrograde iliac endarterectomy was performed in 7 patients, SFA endarterectomy in 105 patients, and combined retrograde iliac and antegrade SFA in 5 patients. The average duration of the procedure was 162 minutes +/- 69 minutes (SD). Half of the patients were discharged on the first postoperative day, and the average length of stay was 2.52 days. The mean follow-up was 19 months, with a primary patency of 70% at 30 months by life-table analysis. Limb salvage was 94%.

CONCLUSIONS

Remote endarterectomy is a viable and durable alternative to standard bypass procedures. It has equivalent patency to published results of bypass or endovascular procedures of the external iliac and superficial femoral arteries and may soon replace bypass as the preferred procedure for long-segment occlusions of these vessels.

Salvage of critical limb ischemia with the "trellis reserve'' of subintimal superficial femoral-popliteal artery occlusion: a new modality in managing critical limb ischemia--a case report

Subintimal angioplasty is a safe, effective, but nondurable procedure in treating long superficial femoral artery occlusions in patients with severe lower limb ischemia. The authors report a case of acute thrombosis that presented 16 weeks after subintimal angioplasty. The ;;Trellis'' percutaneous thrombolytic infusion system permitted a controlled site-specific infusion of recombinant tissue-type plasminogen activator (rtPA). The unique design of the ;;Trellis'' allowed complete aspiration of thrombus and avoiding regional and systemic thrombolytic side effects. The ;;Trellis'' system is effective in percutaneous management of thrombotic lesions; however, intimal dissection may need to be addressed.

Remote iliac artery endarterectomy: seven-year results of a less invasive technique for iliac artery occlusive disease

OBJECTIVE

Remote endarterectomy of external and common iliac artery occlusions through a single, groin incision under fluoroscopic guidance is a relative unknown surgical procedure. This prospective single center cohort study describes this less invasive endovascular technique with the ring strip cutter and its early complications. The results at midterm follow-up are presented.

PATIENTS AND METHODS

From April 1994 to July 2001, 49 remote-endarterectomies of the external or common iliac artery were performed in a retrograde manner from a single, groin incision in 48 patients (30 men, 31 procedures). The median age was 66 years (39 to 82 years). Indications for operation were as follows: severe claudication in 28 (57%), rest pain in 13 (27%), and gangrene in 8 (16%) procedures. Follow-up included clinical evaluation, ankle-brachial index, and duplex scanning at 6 weeks, 3 months, and yearly thereafter.

RESULTS

Intraoperative technical success was achieved in 43 (88%) procedures. A retroperitoneal incision was necessary in three patients for an additional arteriotomy in the iliac artery and in three others for a bypass procedure. The mean follow-up was 20 months (2 to 77 months). Three-year cumulative primary patency rate by means of life table analysis was 60.2% +/- 12.0 (SE). During follow-up, percutaneous transluminal balloon angioplasty with and without stenting was performed in six and two patients, respectively, resulting in a 3-year primary-assisted patency rate of 85.7% +/- 9.56. Three-year secondary patency was 94.2% +/- 5.50.

CONCLUSIONS

Remote endarterectomy in external and common iliac arterial occlusive disease is a feasible endovascular procedure with a low complication rate. The midterm primary-assisted patency rate is good.

Remote endarterectomy: first choice in surgical treatment of long segmental SFA occlusive disease?

OBJECTIVES

to report the long term results of remote superficial femoral artery endarterectomy (RSFAE) with the MollRing Cutter for the treatment of long segmental SFA occlusive disease.

DESIGN

retrospective open study.

PATIENTS AND METHODS

from March 1994 to August 2000 183 RSFAEs were performed in 164 selected patients (105 males, 120 procedures) with a median age of 63 years (43-84 years). Indications for operation were disabling intermittent claudication in 129 procedures (70%), rest pain in 20 procedures (11%), and limb salvage in 34 procedures (19%). Follow up consisted of clinical evaluation, ankle-brachial index measurements and duplex scanning.

RESULTS

the mean follow-up time was 29.3 months. The mean length of the endarterectomised SFAs was 31 cm (range, 17-45cm). The five year cumulative primary patency rate by means of life table analysis was 37.8+/-6.67% (SE). Percutaneous transluminal balloon angioplasty and surgical re-intervention were performed in twenty-nine and four patients respectively resulting in a primary assisted patency rate of 47.9+/-6.27%. Limb salvage was achieved in 30 of the 34 patients. Females had a statistically significant lower primary patency rate, i.e., 26 vs 45% (p -value=0.01).

CONCLUSIONS

the long term results of remote SFA endarterectomy show that it is a safe, effective and durable, minimally invasive procedure. It also leaves open all other options for conventional bypass procedures. The five-year primary patency rate is at least similar to prosthetic above-knee bypass surgery.