Common femoral artery endarterectomy for lower-extremity ischemia: evaluating the need for additional distal limb revascularization

Rafael D Malgor, Joseph J Ricotta, Thomas C Bower, Gustavo S Oderich, Manju Kalra, Audra A Duncan, Peter Gloviczki
Annals of Vascular Surgery 2012, 26 (7): 946-56

BACKGROUND: The role of common femoral artery endarterectomy (CFE) and the need for distal revascularization is challenging in certain clinical scenarios. For some patients with claudication or rest pain CFE alone may suffice, however, some surgeons advocated that in-line flow must be re-established in patients with major tissue loss for wound healing purposes. The decision when to perform CFE with or without distal revascularization is sometimes difficult. The objective of this study was to evaluate the outcomes of common femoral artery endarterectomy (CFE) to define predictive factors for additional distal revascularization.

METHODS: Retrospective review of 262 consecutive CFEs in 230 patients with lower-extremity ischemia between 1997 and 2008. Patients were divided into two groups: group A (n = 169; CFE alone) and group B (n = 93; CFE + distal revascularization). Concomitant iliac intervention was included only if performed by endovascular approach. Patients were analyzed by Rutherford category (RC) and TransAtlantic InterSociety Consensus (TASC) II classification. Primary end points were mortality, patency, reintervention, and limb salvage.

RESULTS: Demographics, preoperative Society for Vascular Surgery score assessment, and TASC II classification did not differ between groups. Mean follow-up was 75 months (range: 1-128 months). Technical success was obtained in all patients. RC (3 ± 1.2 vs. 5 ± 1.4; P = 0.001), diabetes (33% vs. 52%; P = 0.005), mean operative time (+154 minutes; P < 0.001), and length of hospital stay (+1.7 days; P = 0.03) were higher in group B. Reintervention rates were higher in group B than group A (12% vs. 3%; P = 0.015). For patients with RC 5/TASC D lesions and patients with RC 6 regardless of TASC, initial distal revascularization (group B) was associated with fewer reinterventions or major amputations (29%) than CFE alone (67%) (P = 0.002). The cumulative 5-year primary patencies for groups A and group B were 96% and 92%, respectively. Secondary patency was 100% at both time points. Limb salvage was also lower in patients with RC 5 and 6 (P = 0.01; P = 0.02). Overall survival was 93% at 1 year and 77% at 5 years. Independent predictors for distal revascularization were RC 5 or 6 (P < 0.001), TASC D lesions (P < 0.0001), diabetes (P = 0.04), and being on anticoagulation (P = 0.003). There was no difference in survival between the two groups for RC 1 to 5 (P = 0.2), but for patients with RC 6, survival was improved in group B (39% vs. 67%; P = 0.9).

CONCLUSION: CFE alone is sufficient for patients with lower-extremity ischemia who present with life-limiting claudication regardless of TASC lesion and for those with RC 5 and TASC lesions A to C. Patients with RC 5 and TASC D lesions and those with major tissue loss (RC 6) regardless of TASC lesion are better served with additional distal revascularization to improve limb salvage, reintervention, and survival rates.

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