A single-center experience in the eversion femoral endarterectomy

Abstract

Objectives

Endarterectomy is the treatment of choice for arterial occlusive disease of the femoral bifurcation. Longitudinal arteriotomy and prosthetic patch angioplasty is the standard technique but, due to the increasing concerns with prosthetic-related infections and multidrug-resistant pathogens our group adopted an alternative approach. We present our experience with eversion femoral endarterectomy.

Methods

All patients submitted to eversion femoral endarterectomy in a single institution during 2016–2019 were retrospectively analyzed. Patient demographics, surgical data, and complications were captured from medical records.

Results

Nineteen patients, 84.2% male and a median age of 67 years (IQR 62–78) were submitted to eversion femoral endarterectomy with a median follow-up of 180 days (IQR 71–395). Seventeen (89.4%) patients were treated for chronic limb ischemia and the other two were submitted to femoral endarterectomy during endovascular aortic aneurysm repair. Most of the patients had smoking history (84.2%), followed by hypertension (68.4%), dyslipidemia (63.2%), coronary heart disease (29.4%), and diabetes (26.3%). Only 3 patients (15.8%) were submitted exclusively to endarterectomy, 13 (68.4%) were submitted to endarterectomy as an adjuvant for peripheral endovascular treatment, 2 (10.5%) as a concomitant procedure to endovascular repair of aortic aneurysm, and 1 (5.3%) was complemented with thrombectomy of the femoro-popliteal sector. Primary patency rates were 100% and 87.5% (CI (38.7–98.1)) at 6 and 12 months, respectively. Primary-assisted and secondary patency rates were 100%. The 30-day mortality rate was 5.3% (n = 1) and complication rate 10.5% (n = 2). One patient complicated with acute renal disease related to rhabdomyolysis. Another patient developed a wound-related hematoma treated with surgical drainage, but died three days after consequent to ischemia-reperfusion injury.

Conclusions

Eversion femoral endarterectomy is a safe and feasible technique, with good patency results and respecting the concept of leaving nothing behind. A careful control of the proximal and distal endpoints is essential for the success of the technique.

Keywords

Endarterectomy eversion patch prosthetic infection occlusive disease

Introduction

The endarterectomy was first described in 1947 by Cid dos Santos and is still the treatment of choice for many patients with arterial occlusive disease involving the common and/or deep femoral artery (DFA).^1–4 Longitudinal arteriotomy and endarterectomy followed by prosthetic patch angioplasty is the most widely reported technique.^2,3,5 However, due to the concerns of prosthetic-related infections, other patch materials were employed like vein, bovine pericardium or endarterectomized superficial femoral artery (SFA).⁶ Another option is the eversion endarterectomy (EE) that was first described by De Bakey et al. to treat carotid and lower limb arterial occlusive disease.⁷ Although it remains a valuable solution for the carotid bifurcation,^8,9 this technique is now less frequently used in the iliofemoral territory, with a few authors reporting their results.^10,11

The aim of this study is to present our experience implementing the eversion femoral endarterectomy technique in selected cases of common femoral occlusive disease.

Materials and methods

Patients and data collection

A retrospective, non-comparative, single-center study was performed in a tertiary hospital. Data from all patients submitted to eversion femoral endarterectomy between 2016 and 2019 were collected. Patients submitted to common femoral endarterectomy by eversion technique with or without involvement of the femoral bifurcation were included. The decision to perform eversion technique was based on surgeons’ preference. All cases not fit for EE, such as, long DFA disease, were submitted to open endarterectomy with patch angioplasty. Patients submitted to a single EE of the SFA were excluded. All patients provided informed consent before treatment and Institutional Review Board approval was waived for this study. Patient’s characteristics included cardiovascular risk factors and other comorbidities collected from hospital medical records. Patients were preoperatively evaluated by clinical examination and imaging methods including duplex ultrasonography, digital subtraction arteriography and/or computed tomography angiography.

Surgical technique

Femoral bifurcation is exposed by a classic groin incision. The common femoral artery (CFA) is obliquely transected at less than 1 cm to the femoral bifurcation (Figure 1(a)), respecting the oblique orientation as represented in Figure 2. With the right oblique orientation, it is possible to extend the arteriotomy in a longitudinal fashion to facilitate and optimize the length extension of the endarterectomy to the SFA (Figure 3(a)) or the DFA (Figure 3(b)). The proximal segment of the CFA is everted to perform the endarterectomy, with particular attention for the transition between the endarterectomized and the nonendarterectomized segments (Figures 1(b) and 4(a)). After that, the endarterectomized CFA is slowly inverted while performing a meticulously cleanse of the inner surface using De Bakey vascular tissue forceps. The distal segment of the CFA is performed in the same way until the femoral bifurcation. At this point, the plaque is divided using Potts or Metzenbaum scissors to allow an individualized endarterectomy of the SFA and DFA (Figure 4(b)). Eversion of the SFA is performed as distally as it is possible supported by a Watson Cheyne dissector (or similar) to detach the plaque in a circumferential fashion (Figure 4(c)). If the endpoint is not accessible by this mean, some options may be explored: (1) perform a straight cut of the atherosclerotic plaque and apply tacking sutures (also known as Kunlin sutures); (2) stenting the endpoint segment after the control arteriography; (3) perform an additional transection of the SFA distally to the bifurcation and proceed to EE of this segment in a retrograde fashion (Figure 2); (4) or remote endarterectomy using a ring stripper and complemented with endovascular stenting if necessary. The DFA usually reveals a limited extension of the atherosclerotic plaque that allows the surgeon to perform a “shorter” EE; when required, a Watson Cheyne dissector can be used to handle the plaque of the DFA in the same way it was described for the SFA (Figure 4(d)). If a flap is detected, it is applied tacking sutures. Finally, residual debris is flushed with heparinized saline solution and the CFA is primarily anastomosed in an end-to-end continuous suture using a 6-0 synthetic monofilament (Figure 1(c) to (d)). All cases are controlled with a final arteriography, with technical success defined by ≤30% residual stenosis.

Figure 1.

Chronological sequence of the eversion femoral endarterectomy: (a) the common femoral artery is obliquely transected at less than 1 cm to the femoral bifurcation; (b) eversion common femoral artery endarterectomy; (c) after distal endarterectomy, an end-to-end continuous anastomosis is performed; (d) final result of the technique.

Figure 2.

The different approaches to perform the arteriotomy of the common femoral artery regarding different occlusive disease patterns.

Figure 3.

A correct oblique orientation of the femoral transection allows a longitudinal arteriotomy in order to optimize the length of the endarterectomy through (a) the superficial femoral artery or (b) the deep femoral artery.

Figure 4.

(a) Eversion endarterectomy of the common femoral artery; (b) division of the atherosclerotic plaque at the level of the femoral bifurcation; (c) extension of the length of the superficial femoral artery endarterectomy with a dissector performing circumferential movements; (d) eversion endarterectomy of the deep femoral artery supported by a dissector.

Follow-up

Patients were routinely evaluated at 1 month, 6 months, 12 months, and then annually. Duplex ultrasound was performed at one month and annually. All data were collected from clinic visits, hospital admissions and readmissions, and diagnostic image evaluations.

Study endpoints and definitions

Technical success of the eversion femoral endarterectomy was obtained with the feasibility of the technique. Patency solely refers to the femoral endarterectomy, excluding any adjuvant procedure. Restenosis was defined as a stenosis >50% in Doppler ultrasound (defined as a stenotic peak velocity ratio of 2.4 (stenotic peak systolic velocity/pre-stenotic peak systolic velocity)).^5,12

Primary patency was defined as the lack of occlusion or restenosis of the femoral endarterectomy. Primary-assisted patency was defined as a patent vessel that needed at least one reintervention for a restenosis >50%. Secondary primary patency was defined as patency after treatment of femoral occlusion. Major amputations included above-knee and below-knee amputations. Early complications or mortality refer when the event occurred within 30 days after the procedure.

Statistical analysis

Descriptive data were presented as median with interquartile range (IQR) from 25th to 75th percentile for continuous variables, and presented by numbers with percentage values for categorical variables. Mann–Whitney test was used to compare continuous variables between groups, and proportions were compared using Fisher’s exact test. Odds ratio (OR) with 95% confidence intervals were estimated using logistic regression. All analyses were considered statistically significant if a two-tailed p value <0.05 was observed. Statistical analysis was carried out using Stata 12.1 (StataCorp®, Lakeway Drive, College Station, TX).

Results

Nineteen patients were submitted to unilateral eversion femoral endarterectomy with a technical success of 100%. The characteristics of the patients are shown in Table 1. The median age was 67 years (IQR 62–78) with a male predominance of 84.2%. Most of the patients have smoking history (84.2%), followed by hypertension (68.4%), dyslipidemia (63.2%), coronary heart disease (29.4%), and diabetes (26.3%). All cases of eversion femoral endarterectomy were primary procedures. Seventeen (89.4%) patients were treated for chronic limb ischemia, two of them handled in an acute ischemic event, with a significant diversity of anatomic patterns of arterial disease (iliofemoral segment: 6; femoral disease: 4; femoropopliteal segment: 1; iliofemoral and femoropopliteal segments: 6). The other two patients were submitted to femoral endarterectomy during endovascular aortic aneurysm repair. Only three patients (15.8%) were submitted exclusively to endarterectomy. Thirteen (68.4%) patients were submitted to eversion femoral endarterectomy as an adjuvant for peripheral endovascular treatment, two (10.5%) as a concomitant procedure to endovascular repair of aortic aneurysm (EVAR, n = 1 and thoracic EVAR (TEVAR), n = 1) and one (5.3%) was complemented with thrombectomy of the femoro-popliteal sector (Table 2). Eversion femoral endarterectomy involving the DFA was necessary in 11 patients, 7 of them involving both DFA and SFA. Angioplasty with stenting of the femoro-popliteal segment were performed in seven patients, four of them included the intimal flap of the SFA.

Table 1.

Baseline characteristics of the patients.

Patients’ characteristics	Total (n = 19)
Patients, n	19
Age yr, median (IQR)	67 (62–78)
Male, n (%)	16 (84.2%)
Risk factors
Smoking history, n (%)	16 (84.2%)
Active smoker, n (%)	10 (52.6%)
Former smoker, n (%)	6 (31.6%)
DM, n (%)	5 (26.3%)
Hypertension, n (%)	13 (68.4%)
Coronary artery disease, n (%)	5 (26.3%)
Dyslipidemia, n (%)	12 (63.2%)
Chronic kidney disease, n (%)	4 (21.1%)
Cerebrovascular disease, n (%)	3 (17.7%)
Atrial fibrillation, n (%)	1 (14.3%)

Table 2.

Intraoperative characteristics and surgical procedures.

Variables	Total (N = 19)
Procedure status, n (%)
Urgent	2 (10.5%)
Elective	17 (89.5%)
Diagnosis, n (%)
Chronic limb disease	15 (78.9%)
Rutherford stage 4	6 (40.0%)
Rutherford stage 5	9 (60.0%)
Acute limb ischemia^a	2 (10.5%)
Type III thoracoabdominal aneurysm^b	1 (5.3%)
Celiac artery aneurysm	1 (5.3%)
Procedures, n (%)
EE (only)	3 (15.8%)
EE + PTA/S of the aorto-iliac sector	6 (31.6%)
EE + PTA/S of the femoro-popliteal sector	1 (5.3%)
EE + PTA/S of the aorto-iliac/femoro-popliteal sector	6 (31.6%)
EE + thrombectomy of the femoro-popliteal sector	1 (5.3%)
EE + TEVAR	1 (5.3%)
EE + Celiac artery embolization, EVAR and SMA chimney	1 (5.3%)

EE: eversion endarterectomy; PTA/S: percutaneous angioplasty and stenting; TEVAR: thoracic endovascular aortic repair; EVAR: endovascular aortic repair; SMA: superior mesenteric artery.

^aBoth patients were in a Rutherford stage 3 before the acute event.

^bCrawford classification of thoracoabdominal aneurysms.

Mortality and complication rates at 30 days were 5.3% (n = 1) and 10.5% (n = 2), respectively. One patient had complicated with acute kidney injury related to rhabdomyolysis caused by ischemia-reperfusion injury. Another patient, who underwent thrombectomy of the femoro-popliteal sector, developed a wound-related hematoma in the first day after arterial revascularization treated with surgical drainage. The same patient died three days after surgery consequent to ischemia-reperfusion injury.

The median follow-up was 180 days, with an IQR between 71 and 395. Primary patency rates were 100% at six months and 87.5% (CI (38.7–98.1)) at 12 months, consequent to a restenosis in the origin of the SFA at seven months of follow-up and treated with stent implantation. No additional restenosis were observed during follow-up. Primary-assisted and secondary patency rates were 100%. During the follow-up, there were no major amputations, wound infections or pseudoaneurysms in the revascularized members.

Discussion

Endarterectomy remains the gold standard technique to approach the femoral bifurcation.¹⁰

The recent Global Vascular Guidelines (GVG) on the Management of Chronic Limb-Threatening Ischemia recommend endarterectomy as the optimal approach to treat CFA disease¹³ and report a five-year primary patency rate between 82.5% and 96%.^2,3,14 Our experience with EE was comparable to the classical technique obtaining a primary patency rate of 87.5% at one year, with no wound infections or pseudoaneurysms during follow-up.

Open endarterectomy with patch angioplasty is the most widely used technique, usually with a prosthetic patch.^2,3,5 However, due to the increasing concerns regarding prosthetic-related infections and the additional spread of multidrug-resistant pathogens other strategies have been employed, such as, patches of vein, bovine pericardium or even an endarterectomized SFA chronically occluded.^6,14 Vein seems to be the best-known patch solution to prevent local complications, with some series reporting zero cases of infection.^6,14 However, harvesting the vein is time consuming and requires additional surgical exploration, sometimes in other anatomic territory. Additionally, the vein is not always available and, when available, could be on the best interest of the patient to preserve it for further procedures in which autologous conduits is virtually unreplaceable (e.g., distal limb bypasses or coronary bypasses).

Bovine pericardium patches have some strong advantages when compared to prosthetic patches, including easy handling, hemostatic suture (i.e., less suture line bleeding), and a theoretically reduced infection rate.¹⁵ Derksen et al. have compared the risk of post-operative surgical-site infection between bovine patches and synthetic patches and did not find a significant difference, obtaining infection rates of 15.7% and 14.9%, respectively.⁶

An endarterectomized patch of a SFA chronically occluded can be a valid solution but precludes a future endovascular recanalization.

The emerging endovascular therapy has led to a shift in the management of the peripheral arterial occlusive disease. There are many concerns regarding the endovascular treatment of the CFA and femoral bifurcation.^2,14 The recent literature reports medium-term outcomes of CFA stenting with restenosis rates of 27.6% for less than one year of follow-up,¹⁶ a primary patency rate of 82.3% at two years,⁵ and a two-year target lesion revascularization rates of 73.2% in chronic limb-threatening ischemia patients.¹⁷ The GVG suggest endovascular approach to CFA as an alternative for highly selected patients such as high surgical risk or hostile groin anatomy.¹³ Endovascular atherectomy could be a future alternative for some patients, but needs further evaluation.¹⁸

De Bakey et al. described EE to treat lower limb ischemia⁷ and extracranial cerebrovascular disease.¹⁹ This technique was almost abandoned to approach the iliofemoral sector but remains a valuable option to treat carotid stenosis.^8,9

Our group adopted the eversion femoral endarterectomy as an alternative to approach the CFA and its bifurcation in selected cases. The main advantage of this technique is related to wound infection. Although the theoretical lower infection risk was not yet demonstrated in the literature,²⁰ it is clear that, when infection occurs, the absence of a prosthetic patch in the femoral artery is very important to avoid the need to replace it by an autologous patch.

As expected, the eversion technique has a learning curve and our previous experience in carotid EE adds some skills to our group. One of the most discussed technicalities related to EE is the endpoint of the endarterectomy. The distal endpoint is of utmost importance for the success of the technique. It is crucial the way the arteriotomy is performed for each case to have the best access to the bifurcation and respective distal arteries (Figure 2). With the right oblique orientation, the surgeon can extent the arteriotomy in a longitudinal fashion to enhance the length extension of the endarterectomy (Figure 3). However, it is important to highlight that EE must be avoided when the disease of the DFA extends beyond the first branches. Fortunately, the atherosclerotic plaque in this artery is frequently circumscribed until the first ramification. However, the DFA must be handled very carefully and, when needed, Kunlin sutures are feasible.

Limitations

The present study has some limitations related to its retrospective design, the small number of patients and medium-term outcomes. We did not report categorical clinical improvement since it was not in the scope of the present study. Our aim was to present our experience in EE as an alternative to open endarterectomy.

Conclusions

Footnotes

Acknowledgements

The authors thank designer Lucy Soares for all the illustrations.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tony R Soares

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