European Journal of Vascular & Endovascular Surgery
Volume 31, Issue 3 , Pages 262-265, March 2006

Remote Superficial Femoral Endarterectomy: Long-term Results

  • K. Devalia
    • ,
  • T.R. Magee
    • ,
  • R.B. Galland

      Affiliations

    • Corresponding Author InformationCorresponding author. R.B. Galland, MD, FRCS, Department of Surgery, Royal Berkshire Hospital, London Road, Reading RG1 5AN, UK.

Department of Surgery, Royal Berkshire Hospital, London Road, Reading RG1 5AN, UK

Accepted 11 October 2005. published online 16 December 2005.

Article Outline

Abstract 

Purpose

The aim of this study was to determine long-term results following successful remote superficial femoral endarterectomy (RSFE).

Methods

RSFE is a minimally invasive technique of revascularising the superficial femoral artery. A single incision was made over the origin of the superficial femoral artery. The endarterectomy was carried out in a closed fashion from above. The cut end of distal atheroma was secured with a stent. Following RSFE patients were followed up with intravenous digital subtraction angiography (IVDSA) and 3-monthly duplex scans. IVDSA was repeated if any abnormality was found.

Results

RSFE was attempted on 30 patients with 33 symptomatic legs to treat tissue loss (n=3), rest pain (n=3) or intermittent claudication (n=27). In 26 limbs it was possible to complete the RSFE satisfactorily (technical success 79%), but during follow-up 18 later developed stenoses. Of 31 stenoses detected, 27 were treated by angioplasty. Primary patency at 1, 2 and 5 years was 38, 31 and 16%, respectively. Primary-assisted patency at 1, 2 and 5 years was 77, 65 and 60%.

Conclusions

Primary-assisted patency following RSFE is reasonable, however, it is only achieved with life-long surveillance and intervention. Until results can be improved the widespread use of RSFE cannot be recommended.

Keywords: Remote endarterectomy, Superficial femoral artery

 

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1. Introduction 

Remote superficial femoral artery endarterectomy (RSFE) is a minimally invasive means of revascularising the superficial femoral artery that provides an alternative to femoro-popliteal bypass or angioplasty.1, 2, 3, 4, 5, 6, 7, 8 The aim of this study is to determine long-term results following successful RSFE.

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2. Methods 

2.1. Technique 

The original technique was described by Moll.1 The procedure is carried out under general anaesthetic through a single groin incision. The common, superficial and profunda femoris arteries are identified. Following administration of 5000IU heparin intravenously the origin of the superficial femoral artery is clamped. A longitudinal arteriotomy is made in the superficial femoral artery and the endarterectomy plane defined. At this point, flow is maintained through the profunda femoris artery. A ring stripper is passed down the superficial femoral artery in the plane of the endarterectomy until it reaches the distal limit of the atheroma. The ring stripper is then removed and the atheroma cut at its distal end using a ‘Moll ring-cutter’ (Medtronic, USA). The atheromatous core is removed and the distal end secured by means of a Palmaz stent (J and J Interventional, USA). A 2.9-cm stent is used with 8mm maximal diameter mounted on a 5-mm balloon. Once the stent is in position the proximal end is funnelled by oversizing the top of the stent using an 8-mm balloon. Thus, blood flows smoothly into the popliteal artery. Following completion angiography, common and profunda femoris arteries are clamped. The arteriotomy in the superficial femoral artery is extended into the common femoral artery, any residual atheroma is removed and the arteriotomy closed with a vein patch. The procedure takes about 90min to complete.

The potential problem with this technique is that when the guidewire is passed from above, prior to placing the stent, the wire can cause further dissection preventing cannulation of distal lumen. This occurred in the first two patients on whom the procedure was attempted. We thus modified the original technique such that a guidewire was passed into the popliteal artery, distal to the occlusion, under local anaesthetic prior to the operative procedure described above.9 The advantage is that the guidewire remains in the lumen of the vessel throughout and having a guidewire in popliteal artery distal to the occlusion also defines accurately the occlusion's lower limit.

2.2. Follow-up 

Ankle-brachial pressure index (ABPI) was carried out before and following the procedure. All patients had an intravenous digital subtraction angiogram (IVDSA) at 24h. Duplex scanning of the superficial femoral artery was carried out at 3-monthly intervals and a further IVDSA carried out if any abnormality was detected. Follow-up was 3–84 months. Patency was calculated by the life table method.

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3. Results 

RSFE was attempted on 30 patients (22 men). Seven had ischaemic heart disease, eight were diabetic and their median age was 64 years (range: 45–84 years). Thirty-three symptomatic legs were treated. All patients had intermittent claudication. In addition, three had rest pain and three ulceration or gangrene. All patients were on best medical treatment to control risk factors. Patients with intermittent claudication had life-style limiting symptoms, which had failed to improve with a 3-month conservative regimen. Previous interventions included percutaneous transluminal angioplasty in six, femoro-popliteal bypass in one, superficial femoral artery endarterectomy in one, femorofemoral cross-over graft in one and abdominal aortic aneurysm repair in one.

In seven cases it was impossible to complete the endarterectomy. This included two patients who had previously had operative procedures on the superficial femoral artery. In three others the vessel was heavily calcified and the procedure could not be completed. In two patients the superficial femoral artery was perforated during endarterectomy. These limbs all underwent successful femoro-popliteal bypass under the same anaesthetic. These cases are not considered further.

In 26 limbs it was possible to complete the RSFE satisfactorily. Follow-up was 3–84 months.

In 22 of 26 instances where the RSFE was successfully completed the patient was discharged within 24h. One patient required an extra night in hospital because of groin pain. Two patients required re-exploration of the groin due to bleeding from the vein patch and one of these patients stayed in hospital an extra 24h. Two patients stayed in for anticoagulation. One patient in whom the run off was thought to be poor had heparinisation for 48h. The other patient had an artificial heart valve and had previously been on warfarin, which required stabilisation following RSFE.

3.1. Duplex surveillance and stenosis development 

Any patient in whom a peak systolic velocity (PSV) greater than 2.5 was identified on duplex scanning underwent an IV DSA. In 18 endarterectomised superficial femoral arteries 31 stenoses were identified. The stenoses developed anywhere along the endarterectomised segment or distally in the region of stent. Fig. 1 shows that the majority of stenoses develop in the first 18 months; however, they continued to develop throughout follow-up. Percutaneous transluminal angioplasty (PTA) was carried out on any stenosis with PSV greater than 2.5. Fig. 2 shows the total number of stenoses recorded.

3.2. Patency 

In 11 cases the artery occluded. Eight occlusions were within the first 2 years. One patient remained asymptomatic following occlusion. Two patients underwent a major amputation following occlusion, both originally presented with rest pain or gangrene. A further three patients underwent femoro-popliteal bypass. In one patient the artery occluded at 5 years and he developed wet gangrene of the foot eventually leading to death from sepsis. In one patient the ABPI fell from 0.62 pre-RSFE to 0.4 following occlusion soon after surgery. He originally presented with intermittent claudication at 50 yards and following occlusion he complained of a white, numb foot. Angiography confirmed a previously undetected iliac stenosis. He underwent PTA of the iliac stenosis followed by thrombectomy of the superficial femoral artery. In the remaining cases, following occlusion symptoms were no worse than before RSFE.

Patency of RSFE is shown in Fig. 3. The primary patency at 1, 2 and 5 years was 38, 31 and 16%, respectively. Primary-assisted patency at 1, 2 and 5 years was 77, 65 and 60%, respectively.

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4. Discussion 

Generally lower limb revascularisation is considered when optimisation of cardiovascular risk factors and an exercise program have failed in patients with intermittent claudication and for those who present with rest pain or tissue loss. Femoro-popliteal bypass using vein leads to better results than endarterectomy, however, the latter may produce results equivalent to a synthetic bypass. The use of endarterectomy, whether open, semi-closed or remote, has advantages of there being no synthetic material for potential infection, the procedure can be used in absence of vein, or veins can be preserved. Following occlusion of the endarterectomy, the limb is no worse than it was pre-operatively in contrast to occlusion of polytetrafluoroethylene (PTFE) grafts which can result in symptoms worse than those originally due to thrombosis of run-off vessels.4

Following RSFE primary-assisted patency was comparable to primary patency following synthetic above-knee femoro-popliteal bypass. The primary and primary-assisted patency at 5 years was 16 and 60%, respectively. Rosenthal et al.10 reported a primary-assisted patency of 88% at 33 months and Moll et al.3 described 86% primary-assisted patency at 2 years.

Superficial femoral artery stenosis development is a major problem after RSFE. Stenoses develop in 30% of vein grafts mostly within the 1st year of operation.11 Our study shows that in approximately two-thirds of patent arteries significant stenoses developed after RSFE, an incidence slightly higher than previously reported as 23–46%.2, 10, 12 We adopted an aggressive policy for dealing with stenoses as in an early case thrombosis developed very soon after a stenosis was identified.

There are obvious short term advantages with RSFE such as cost advantages due to a short hospital stay. This is comparable with that expected following PTA and better than would be expected after femoro-popliteal bypass. The other advantage is that if a vein is present, it can be preserved for future use. However, the cost advantages are largely offset by lifelong duplex surveillance and PTA to maintain patency.4

Currently there are multicentre studies underway to evaluate feasibility and efficacy of an innovative new covered stent and adjustable deployment system (aSpire trade mark covered stent, Vascular Architects Inc., San Jose, USA) in combination with RSFE for the treatment of long segment femoro-popliteal occlusive disease. The medium term follow up appears favourable with cumulative primary and primary-assisted patency rates of 60 and 70%, respectively, at 18 months.13, 14

In conclusion, based on these data RSFE cannot be recommended for widespread use.

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References 

  1. Moll FL, Ho GH, Joosten PP, Van de pavoordt HD, Overtoom TT. Endovascular remote endarterectomy in femoropopliteal segment occlusive disease. A new surgical technique illustrated and preliminary results using a ring strip cutter device. J Cardiovasc Surg (Torino). 1996;37(Suppl 1):39–40
  2. Ho GH, Moll FL, Hedeman Joosten PP, van de Pavoordt HD, van den Berg JC, Overtoom TT. Endovascular remote endarterectomy in femoropopliteal occlusive disease: one-year clinical experience with the ring strip cutter device. Eur J Vasc Endovasc Surg. 1996;12:105–112
  3. Moll FL, Ho GH. Closed superficial femoral artery endarterectomy: a 2-year follow-up. Cardiovasc Surg. 1997;5:398–400
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  5. Pursell RJ, Pittathankal AA, Galland RB. Management of occlusive disease of the superficial femoral artery. Recent Res Dev Radiol. 2003;144–145Chapter 9, published by Transworld Research Network
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  8. Florenes T, Bay D, Sandbaek G, Saetre T, Jorgensen JJ, Slagsvold CE, et al. Subintimal angioplasty in the treatment of patients with intermittent claudication: long term results. Eur J Vasc Endovasc Surg. 2004;28:645–650
  9. Whiteley MS, Magee TR, Torrie EP, Galland RB. Minimally invasive superficial femoral artery endarterectomy: early experience with a modified technique. Eur J Vasc Endovasc Surg. 1998;16:254–258
  10. Rosenthal D, Martin JD, Schubart PJ, Wellons ED. Remote superficial femoral artery endarterectomy. Cardiovasc Surg. 2004;45:185–192
  11. Taylor P, Wolfe J, Tyrell M, Mansfield AO, Nicolaides AN, Houston RE. Graft stenosis: justification for 1-year surveillance. Br J Surg. 1990;77:1125–1128
  12. Smeets L, Ho GH, Hagenaars T, van den Berg JC, Teijink JAW, Moll FL. Remote endarterectomy: first choice in surgical treatment of long segment SFA occlusive disease?. Eur J Vasc Endovasc Surg. 2003;25:583–589
  13. Rosenthal D, Martin JD, Schubart PJ, Wellons ED, Shuler FW, Levitt AB. Remote superficial femoral artery endarterectomy and distal aSpire stenting: multicenter medium-term results. J Vasc Surg. 2004;40:67–72
  14. Knight JS, Smeets L, Morris GE, Moll FL. Multi centre study to assess the feasibility of a new covered stent and delivery system in combination with remote superficial femoral artery endarterectomy (RSFAE). Eur J Vasc Endovasc Surg. 2005;29:287–294

PII: S1078-5884(05)00652-0

doi:10.1016/j.ejvs.2005.10.019

European Journal of Vascular & Endovascular Surgery
Volume 31, Issue 3 , Pages 262-265, March 2006

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