Femoral Endarterectomy for Severe Peripheral Arterial Disease

This case describes an 85-year-old gentleman with significant peripheral arterial disease and lifestyle-limiting claudication who had previously undergone an unsuccessful attempt at endovascular treatment of his significant right common femoral artery stenosis. At our institution, we proceeded with open surgical intervention and performed a right common femoral endarterectomy to remove his significant plaque burden. Postoperatively, the patient noted significant improvement in his right lower extremity claudication, and his postoperative pulse volume recordings show improved arterial inflow. This article provides background information regarding this particular patient’s case, as well as a detailed description of the steps of the surgical procedure itself.

Claudication; endarterectomy; peripheral arterial disease.

A femoral endarterectomy is a common vascular surgical procedure that is performed to remove bulky atherosclerotic plaque from the femoral artery. It is one option for treatment in patients with symptomatic peripheral vascular disease who have a focal area of stenosis in the femoral artery. This and other management options are discussed in the case below.

The patient is an 85-year-old male with a history of stage 3 chronic kidney disease, coronary artery disease (history of a 2-vessel CABG), atrial fibrillation (history of Watchman placement, and thus not on anticoagulation), heart failure with preserved ejection fraction, carotid stenosis (history of bilateral carotid endarterectomies in 2008 and 2009), and peripheral arterial disease (PAD). Regarding his PAD, he has a history of aortoiliac stenosis and underwent kissing common iliac stent placement and right external iliac artery stent placement at an outside hospital in 2010 due to symptoms of claudication in both legs; this procedure had provided temporary relief from his claudication, but his symptoms began to recur, and he presented to our institution for evaluation.

On evaluation at our institution, the patient endorsed progressively worsening claudication in both legs, though more noticeable in the right leg compared to the left. He was experiencing symptoms after walking less than 50 feet. His symptoms were interfering with his daily quality of life, and he was unable to perform many of his normal daily activities. Of note, he had not developed rest pain or wounds on his feet. Given the significant and limiting nature of the patient's symptoms, he was taken for an angiogram with plan for possible revascularization of the right leg.

Aortogram demonstrated excellent inflow and normal flow through the previously-placed bilateral kissing common iliac stents as well as the external iliac stent on the patient's right. Angiogram of the right lower extremity demonstrated significant stenosis within the common femoral artery that was almost occlusive. The profunda femoral artery was robust, and the superficial femoral artery reconstituted in the mid-thigh, leading to a patent popliteal artery and three-vessel runoff to the level of the foot. Given the near-occlusive nature of the patient's common femoral artery lesion, it was determined that the patient would likely benefit from a femoral endarterectomy. Angioplasty of the common femoral artery with a drug-coated balloon was performed to provide some immediate symptomatic relief, with plan to then proceed in the near future to the OR for surgical intervention.

On physical exam, the patient was well-appearing overall. He was in normal sinus rhythm and breathing comfortably on room air. He had a 2+ femoral pulse on the left and a diminished 1+ femoral pulse on the right. His pedal pulses were not palpable, but he had multiphasic dorsalis pedis and posterior tibial Doppler signals bilaterally. There were no wounds on the feet.

An initial pulse volume recording (PVR) study was notable for diminished waveforms of the bilateral lower extremities, more notable in the right leg than the left. On the right side, the patient had an ankle-brachial index (ABI) of 0.42, a toe-brachial index (TBI) of 0.16, and a toe pressure of 24. On the left side, the patient had an ABI of 0.16, a TBI of 0.71, and a toe pressure of 107.

An angiogram had been performed prior to the patient's open surgical intervention. As detailed above, angiogram of the right lower extremity demonstrated significant stenosis within the common femoral artery that was almost occlusive. The profunda femoral artery was robust, and the superficial femoral artery reconstituted in the mid-thigh, leading distally to a patent popliteal artery and three-vessel runoff to the level of the foot.

Among patients who experience claudication, only approximately 5% will progress to amputation within 5 years.¹ Given this fact, when symptoms of claudication are mild or moderate, it is often advantageous to first start the patient on a structured exercise regimen and optimized medical management rather than proceeding to endovascular or open surgical intervention, as these surgical procedures are not without risk. However, when symptoms are severe enough to interfere with daily activities and cause a significant impact on quality of life, consideration of open surgery or endovascular intervention can be made.

Atherosclerotic disease can be managed medically in some patients who have mild to moderate symptoms of claudication and who are compliant with their medications. Medical management can include antiplatelet therapy and statin therapy, in combination with a structured exercise program as well as a healthy diet and avoidance of tobacco.^1,2 When patients have progressed to lifestyle-limiting claudication, consideration can be made for intervention via endovascular or open surgical techniques. If the patient has progressed to rest pain or tissue loss, this falls under the category of chronic limb threatening ischemia, and intervention should be made in a timely fashion.³ Progression to acute limb ischemia requires urgent or emergent action.⁴

The patient in this case was experiencing lifestyle-limiting claudication. Endovascular intervention had been attempted and was not successful due to the degree of stenosis within the common femoral artery. Therefore, the decision was made to proceed with open surgical intervention.

While this patient experienced a more beneficial outcome from his open femoral endarterectomy compared to the attempt at endovascular revascularization of his femoral artery, this will not be the case with all patients. Each patient should be evaluated on a case-by-case basis to decide whether open surgical intervention versus endovascular intervention would be a preferable approach. Additionally, even in the setting of lifestyle-limiting claudication, one could opt to proceed with attempts at nonsurgical management (optimized medical therapy, structured exercise, healthy diet, and tobacco cessation).

After informed consent was obtained, the patient was brought to the operating room and placed on the operating room table in the supine position. General endotracheal anesthesia was administered. His bilateral groins were prepped and draped in the standard sterile fashion. A hard timeout was performed to identify the correct patient, procedure, and laterality. We marked the right anterior superior iliac spine and the right pubic tubercle, and drew a line between these to approximate the location of the inguinal ligament. We identified our common femoral artery just inferior to this by both palpation and by ultrasound imaging.

We made a longitudinal incision over the right femoral artery. We then dissected down through the subcutaneous soft tissue with cautery. We opened the femoral sheath and then proceeded with sharp dissection to identify the underlying common femoral, superficial femoral, and profunda femoral arteries. These arteries were identified and isolated, and were controlled with vessel loops. We also identified and ligated the proximal crossing vein overlying the proximal common femoral artery, and achieved proximal control at the level of the distal external iliac artery. We then administered systemic heparinization, and then placed clamps on the distal external iliac artery, the profunda femoral artery, and the superficial femoral artery.

An arteriotomy of the common femoral artery was performed using an 11 blade scalpel, and then Potts scissors were used to extend the arteriotomy both proximally and distally to locate the endpoints of the plaque. We used a Freer elevator to carefully remove the plaque from the artery wall. A feathered end point was achieved at both the proximal and distal ends of the plaque. We confirmed robust back-bleeding from the superficial femoral artery and the profunda femoral artery, as well as robust inflow from the distal external iliac artery.

A bovine pericardial patch was then brought onto the field. This was carefully cut to size to match the arteriotomy. 6-0 Prolene suture was used to sew the bovine pericardial patch in place over the arteriotomy. Prior to placing our final stitches in the patch, we again confirmed robust back-bleeding and excellent inflow, and then completed sewing the patch in place. A Doppler was used to confirm triphasic signals in the distal external iliac artery, the common femoral artery at the level of the patch repair, the superficial femoral artery, and the profunda femoral artery. PVRs were taken at the bilateral ankles, and they were equal and pulsatile bilaterally.

Hemostasis was achieved using electrocautery. The groin was closed in 4 layers, using layers of 2-0 and 3-0 Vicryl to close the tissues, and then followed by 4-0 Monocryl to close the skin. Skin glue was applied over the incision. All instrument counts were confirmed to be correct. The patient was then extubated and was taken to the recovery area in stable condition.

Total operative time was 2 hours 46 minutes. Estimated blood loss was 100 cc. There were no intraoperative complications. The patient’s postoperative recovery was uneventful, and he was discharged on postoperative day 2.

He had been evaluated in the outpatient clinic for his postoperative follow-up visit, and he has been recovering well from his procedure. His right groin incision has healed well. His symptoms of claudication have lessened; he can now walk several hundred feet before he starts to develop cramping in his calves, and he no longer feels that his symptoms are having a significant impact on his daily life. He continues on his antiplatelet and statin medications at this time, and is abstaining from smoking. We are continuing to monitor him in the outpatient setting with clinic visits to monitor his symptoms as well as routine PVR studies as an objective way to monitor his arterial flow.

Notable equipment or implants for this procedure was the bovine pericardial patch. We used a tapered 2 x 9-cm biologic bovine pericardial patch that is manufactured by LeMaitre Vascular, Inc. that was trimmed to an appropriate size before placement.

The authors have nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

The authors would like to thank the patient described in this case, who courteously agreed to provide his story for the education of others.