Remote Superficial Femoral Endarterectomy: Long-term Results

Single-Center Experience With Remote Endarterectomy for the Treatment of Long-Segment Superficial Femoral Artery Occlusion: Long-Term Results

OBJECTIVES

Remote endarterectomy (RE) is a relatively minimally invasive procedure as an alternative to femoropopliteal above-knee bypass for the treatment of long-segment superficial femoral artery (SFA) occlusion. The objective of this study was to report our experience and to evaluate the long-term outcome.

DESIGN

Single-center nonrandomized retrospective study with prospective collection of patients' data.

METHODS

Twelve patients (11 men; mean age 72 years, range 55-81 years) with long (>10 cm) SFA occlusion underwent RE followed by stent (aSpire) placement at the distal end of the endarterectomy. All patients had at least 2 tibial vessels outflow. Indications were severe claudication in 9 (75%), rest pain in 1(8%), and gangrene in 2 (17%) cases. Technical, hemodynamic success rates and clinical improvement were recorded. Assessment of patency and limb loss was made at a mean follow-up of 50 months (range 12-66 months).

RESULTS

Technical success rate was 100%. Immediate hemodynamic and clinical improvement were 92% and 75%, respectively. The mean increase in the Ankle-Brachial pressure index was 0.24. The primary, primary-assisted, and secondary patency rates were 50%, 83%, and 100%, respectively. The perioperative mortality rate was 8% (one death due to myocardial infarction). There was no early (30-day) reocclusion. During the follow-up, 5 (41.6%) cases underwent 7 reinterventions, all by endovascular means. The amputation rate was 16% (2 of 12).

CONCLUSIONS

The RE for long SFA occlusion is a feasible procedure with acceptable short- and long-term outcomes in the presence of distal arterial outflow. Good long-term patency and limb salvage can be achieved with close surveillance and with the compensation of endovascular reintervention procedures.

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.

Peripheral atherectomy in TransAtlantic InterSociety Consensus type C femoropopliteal lesions for limb salvage

BACKGROUND

The optimal therapy for TransAtlantic Societal Consensus (TASC) type C femoropopliteal lesions remains a critical issue in the treatment of infrainguinal occlusive disease. The purpose of this study was to evaluate the outcome of limbs with TASC C femoropopliteal lesions and critical limb ischemia treated with the FoxHollow SilverHawk atherectomy catheter.

METHODS

From September 2004 to September 2005, 18 consecutive femoropopliteal procedures performed in 17 limbs in 16 patients were reviewed. Demographic data, baseline angiographic findings, and indications for the procedures were recorded. Clinical outcomes including symptom resolution and limb salvage were determined for the 17 primary procedures. Hemodynamic improvement was compared by using the paired Student t test. Stenosis-free patency was determined by the Kaplan-Meier method.

RESULTS

The mean age was 72.5 years (range, 47-88 years). Fifty percent of the patients had four or more of the following risk factors: hypertension, diabetes, tobacco use, hyperlipidemia, renal insufficiency, and coronary artery disease. The indication was tissue loss in 13 limbs and rest pain in 4. All patients had a second level of disease, either inflow or tibial/pedal, which was treated concurrently when appropriate. Initial resolution of symptoms was achieved in 12 limbs, and partial healing was achieved in 2 others. Early amputation was necessary in the remaining three patients, but this was likely due to severe inframalleolar disease and advanced forefoot ischemia at the time of presentation. Five patients have remained symptom-free without restenosis at a mean follow-up of 6 months. Two patients have required late amputation for hemodynamic failure. The ankle-brachial index improved from 0.39 +/- 0.08 (mean +/- SEM) before surgery to 0.75 +/- 0.08 in the immediate postoperative period (P = .02). However, it returned toward baseline at 6 months after surgery, with a mean of 0.48 +/- 0.07. Stenosis-free patency of the femoropopliteal segment was 22% at 12 months.

CONCLUSIONS

Peripheral atherectomy can achieve good early clinical and hemodynamic success in patients with TASC C lesions and critical limb ischemia. However, mid-term restenosis rates are high in this challenging cohort of patients.

Ultrasonic endarterectomy for long superficial femoral artery atherosclerotic occlusive disease

OBJECTIVE

To report the long term results of ultrasonic superficial femoral artery endarterectomy (USFAE).

DESIGN

Retrospective study.

PATIENTS AND METHODS

From January 1998 to June 2004 218 USFAE were performed in 202 selected patients (178 males, 192 procedures) with a median age of 65 years (46-87 years). Indications for operation were disabling intermittent claudication in 137 procedures (68%), rest pain in 24 procedures (12%), and limb salvage in 41 procedures (20%). The new medical technology of ultrasonic endarterectomy is based on the application of the mechanical vibrations in the range of low frequency ultrasound. The ultrasonic device consists of the ultrasonic generator, acoustic unit and the flexible wave concentrators with special working tips in the shape of a ring. Follow up consisted of clinical evaluation, ankle-brachial index measurements and duplex scanning.

RESULTS

The mean follow-up time was 30.1 months. The mean length of the endarterectomised SFAs was 29 cm (range, 15-43 cm). The five year cumulative primary patency rate by means of life table analysis was 45.8 +/- 4.4% (SE). Percutaneous transluminal balloon angioplasty and surgical re-interventions were performed in thirty three and five patients respectively resulting in a primary assisted patency rate of 57.5 +/- 4.1%. The five year secondary patency rate was 65.6 +/- 3.8%. Limb salvage was achieved in 35 of the 41 patients with gangrene.

CONCLUSIONS

The long term results of ultrasonic SFA endarterectomy suggest this is an effective technique.