Isolated femoral artery revascularisation with or without iliac inflow improvement – a less invasive surgical option in critical limb ischemia
Abstract
Summary:Background: Isolated femoral artery revascularisation (iFAR) represents a well-established surgical method in the treatment of peripheral arterial disease (PAD) involving common femoral artery disease. Data for iFAR in multilevel PAD are inconsistent, particularly in patients with critical limb ischemia (CLI). The aim of the study was to evaluate the outcome of iFAR in CLI regarding major amputation and reintervention and to identify associated risk factors for this outcome. Patients and methods: The data used have been derived from the German Registry of Firstline Treatment in Critical Limb Ischemia (CRITISCH). A total of 1200 patients were enrolled in 27 vascular centres. This sub-analysis included patients, which were treated with iFAR with/without concomitant iliac intervention. For detection of risk factors for the combined endpoint of major amputation and/or reintervention, selection of variables for multiple regression was conducted using stepwise forward/backward selection by Akaike’s information criterion. Results: 95 patients were included (mean age: 72 years ± 10.82; 64.2% male). Of those, 32 (33.7%) participants reached the combined endpoint. Risk factor analysis revealed continued tobacco use (odds ratio [OR] 2.316, confidence interval [CI] 0.832–6.674), TASC D-lesion (OR: 2.293, CI: 0.869–6.261) and previous vascular intervention in the trial leg (OR: 2.720, CI: 1.037–7.381) to be associated with reaching the combined endpoint. Conclusions: iFAR provides a reasonable, surgical option to treat CLI. Lesion length (TASC D) seems to have a negative impact on outcome. Further research is required to better define the future role of iFAR for combined femoro-popliteal lesions in CLI – best in terms of a randomised controlled trial.
References
1 . Common femoral artery occlusive disease: contemporary results following surgical endarterectomy. J Vasc Surg. 2008;48(4):872–7.
2 . Common femoral artery endarterectomy for occlusive disease: an 8-year single-center prospective study. Surgery. 2010;147(2):268–74.
3 . Long-term outcome after isolated endarterectomy of the femoral bifurcation. World J Surg. 2008;32(1):51–4.
4 Results of common femoral artery thromboendarterectomy evaluation of a traditional surgical management in the endovascular era. J Vasc Surg. 2016;64(4):995–1001.
5 Isolated endarterectomy of femoral bifurcation in critical limb ischemia: is restoration of inline flow essential? Angiology. 2011;62(2):119–25.
6 Isolated femoral endarterectomy: impact of SFA TASC classification on recurrence of symptoms and need for additional intervention. J Vasc Surg. 2009;50(4):784–9.
7 Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45(Suppl S):S5–67.
8 . Surgery in combined aorto-iliac and femoro-popliteal occlusive lesions (author’s transl). Zentralbl Chir. 1979;104(8):519–28.
9 . Pro and contra profundaplasty (author’s transl). Zentralbl Chir. 1982;107(8):440–7.
10 A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia. Eur J Vasc Endovasc Surg. 2019;58(1S):S110–S9.
11 Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg. 2019;58(1S):S1–S109 e33.
12 . Current practice of first-line treatment strategies in patients with critical limb ischemia. J Vasc Surg. 2015;62(4):965–73 e3.
13 Early results of external iliac artery stenting combined with common femoral artery endarterectomy. J Vasc Surg. 2002;35(6):1107–13.
14 Outcome of patients with chronic limb-threatening ischemia with and without revascularization. VASA. 2020;49(2):121–7.
15 The natural history of untreated severe or critical limb ischemia. J Vasc Surg. 2015;62(6):1642–51.e3.
16 Clinical significance of perioperative changes in ankle-brachial index with regard to extremity-related outcome in non-diabetic patients with critical limb ischemia. Langenbecks Arch Surg. 2018;403(6):741–8.
17 . Development of arteriosclerosis. Pathologe. 2019;40(5):559–72.
18 . The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol. 2004;43(10):1731–7.
19 Cigarette smoking intensity informs outcomes after open revascularization for peripheral artery disease. J Vasc Surg. 2019;70(6):1973–83.e5.
20 . One-Year Results of First-Line Treatment Strategies in Patients With Critical Limb Ischemia (CRITISCH Registry). J Endovasc Ther. 2018;25(3):320–9.
21 Revascularization to an isolated (“blind”) popliteal artery segment: a viable procedure for critical limb ischemia. Surgery. 2009;145(4):426–34.
22 Endovascular treatment of common femoral artery obstructions. J Vasc Surg. 2011;53(4):1000–6.
23 Endovascular treatment of common femoral artery disease: medium-term outcomes of 360 consecutive procedures. J Am Coll Cardiol. 2011;58(8):792–8.
24 Stenting or Surgery for De Novo Common Femoral Artery Stenosis. JACC Cardiovasc Interv. 2017;10(13):1344–54.
25 . Treatment of lymphatic complications after common femoral artery endarterectomy. Ann Vasc Surg. 2020;62:382–6.
26 Design and rationale of the best endovascular versus Best Surgical Therapy for Patients With Critical Limb Ischemia (BEST-CLI) Trial. J Am Heart Assoc. 2016;5(7).
27 . The BEST-CLI trial is nearing the finish line and promises to be worth the wait. J Vasc Surg. 2019;69(2):470–81.e2.
28 Bypass versus angioplasty in severe ischaemia of the leg – 2 (BASIL-2) trial: study protocol for a randomised controlled trial. Trials. 2016;17:11.
