Semiclosed and Remote Endarterectomy of the Superficial Femoral Artery

Omar El-Zoubi MD*, Jan Alshishani MD*, Hayel Al Edwan MD**, Ashraf Alshbatat MD* Kifah Hammad SN^, Fadi Falah MD*

ABSTRACT

Objective: To evaluate the feasibility of semiclosed and remote endarterectomy for the treatment of occlusive superficial femoral artery disease. Methods: During 2005 and 2006, 31 patients (aged 25-81) with critical lower limb ischemia and disabling claudication whom underwent endarterectomy of the superficial femoral artery using ring stripper in the vascular surgery department at Queen Alia hospital in Amman, were reviewed. Semiclosed endarterectomy technique was performed in 21 patients and remote endarterectomy in 10 patients. The procedure with its suspected outcome and complications was discussed with the patients including other treatment options. Written Ethical Approval was obtained from all the study patients. Results: In 29 patients clinical success in the form of restoration of blood supply with limb salvage and alleviation of rest pain and disabling claudication was achieved which was the main goal. Clinical success rate was 94%. Two patients ended up with below knee amputation with a failure rate of 6%. One patient died postoperatively with a mortality rate of 3%. During the two years follow-up period, another three patients died, which was not related to surgery. Conclusion: Semiclosed and remote endarterectomy using ring stripper is a useful technique in the treatment of occlusive arterial lesions of the superficial femoral artery and should be considered as one of the treatment options among selected cases.

Key words: Superficial femoral artery (SFA), semiclosed endarterectomy, remote endarterectomy, ring stripper.

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(1) Introduction thromboendarterectomy”. With gradual introduction of femoropopliteal bypassing by Kunlin The beginnings of femoral artery revascularization in 1949, the bypass technique has gained can be traced back to the early postwar years in predominance.(2) As early as 1967, Jorg Vollmar 1947, in a paper by Joao Cid Dos Santos, who preferred semi-closed endarterectomy as a named the procedure “superficial femoral artery

From the Departments of: *Vascular Surgery, King Hussein Medical Center, (KHMC), Amman-Jordan **Anesthesia and Intensive Care, KHMC ^ Nursing, KHMC Correspondence should be addressed to Dr. J. Al-Shishani, KHMC, E-mail: [email protected] Manuscript received August 8, 2010. Accepted February 10, 2011

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Table I: Ischemia scale and postoperative results Ischemia scale Preoperative Postoperative Disabling claudication 13 All claudications free Rest pain 8 8 minor amputations Tissue loss 10 2 major amputations

Fig. 1. Vollmar ring stripper Fig. 2. Semiclosed Endarterectomy

Fig. 3. Superficial femoral artery plaque Fig. 4. Moll ring cutter

minimally invasive surgical procedure using a ring Limb Ischemia (CLI) in the form of tissue loss in stripper. Also, mention should be made of the use of 10 patients, CLI in the form of rest pain in 8 patients Dotter and Judkin’s coaxial catheter and Grünzig’s and disabling claudication in 13 patients, (Table I). procedure of percutaneous transluminal angioplasty Duplex ultrasound, conventional angiography or from 1974, as considerable advancements in the Computerized Tomographic Angiography (CTA) field of endovascular technique.(2) Remote were the diagnostic tools to delineate the extension endarterectomy, a procedure introduced by Ho and of the disease. At the beginning we started to Moll in 1995, is a minimally invasive procedure that perform this type of surgery in patients with tissue is performed through a small inguinal incision, loss and unsuitable veins for bypass surgery. Later, which allows complete debulking of the arterial patients with rest pain or disabling claudication were plaque and placement of a distal stent, as treated using this technique, selecting patients for indicated.(1) Semiclosed and remote SFA this method was intraoperative, excluding those endarterectomy is an operation which can be patients with diffuse atherosclerosis and in cases of performed through two or a single incision sparing acute ischemia we didn’t apply this method. the long saphenous vein and avoiding the use of Under spinal or epidural anesthesia the Common prosthetic material.(1) Femoral Artery (CFA), Superficial Femoral Artery This study was conducted to evaluate the (SFA), Deep Femoral Artery (DFA) and Popliteal feasibility of semiclosed and remote endarterectomy Artery were exposed through longitudinal inguinal for the treatment of occlusive superficial femoral and distal thigh incisions. The adductor canal was artery disease. opened. After systemic heparinization two arteriotomies were made; a longitudinal arteriotomy Methods at the origin of the SFA and another longitudinal or Thirty-one patients underwent semiclosed and transverse arteriotomy at the Popliteal Artery at the remote endarterectomy in the Vascular Surgery distal end of the lesion (Semiclosed Department in Queen Alia Hospital during 2005 and Endarterectomy). The cleavage plane between the 2006. The indications for operation were Critical plaque and the deep media/adventitia layer usually

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Table II: Comparison of end results between endovascular stenting, surgical bypass and SFA endarterectomy End result Percutaneous stenting SFA endarterctomy Surgical femoropopliteal bypass Perioperative death 0 0 0 Unrelated death 7/113 1/31 5/88 Myocardial infarction 9/113 2/31 7/88 Limb loss 11/113 2/31 7/88 Repeat procedures 14/113 0 2/88 became prominent after performing the arteriotomy. prophylactic low molecular weight heparin and Patients with diffuse arteriosclerosis will not show 100mg aspirin. Aspirin treatment was continued this cleavage plane and they are not suitable for this after discharge. The patients were followed by technique. Endarterectomy was commenced in the regular visits to the clinic with an ankle brachial standard cleavage plane between the inner and outer pressure index (ABPI) and Colour Flow Duplex. media. The intimal core was transversely cut at the SFA origin and threaded into the loop of a Results conventional vollmar ring stripper (Fig. 1). Traction In 29 patients restoration of blood supply with limb is applied at the intimal core and the ring stripper is salvage was achieved which was the main goal. advanced distally down the SFA beyond the Clinical success rate regarding limb salvage and occluded segment using rotation and thrusting alleviation of rest pain was 94%. Out of those 29 motion for spiral dissection (Fig. 2). The patients, toe amputation was required in 5 patients atheromatous core along the entire column of plaque and forefoot amputation in another three after was removed, in 4 patients of those the plaque was restoration of arterial blood supply making limb removed retrograde through the popliteal salvage possible with minor amputations. arteriotomy. The length of the endarterectomized Below knee amputation was performed in two SFAs ranged from 16-32 cm (Fig. 3) and the patients during the postoperative period, one for 40 endarterectomized segment was irrigated with years old male patient who was having multilevel heparinized saline followed by primary closure of arterial occlusive disease including distal crural the transverse arteriotmies and by using vein patches arteries, the second patient was an 81 year old male for closure of the longitudinal arteriotomies. patient with extensive foot infection who died Successful recanalization was confirmed using within the same hospitalization from sepsis. Failure flowmeter, palpation of distal pulses and detection rate was 6% and postoperative mortality was 3%. of distal Doppler signals. Over the follow-up period of 2 years, one patient In 9 patients, the SFA endarterectomy was died 4 months after surgery and another patient died performed through a single incision, then the one year after surgery, both deaths were due to procedure preceded as mentioned above, and distal myocardial infarction. One patient died 18 months incision was not needed, because distal end of the after surgery due to unrelated cause. This procedure plaque was tapered indicated it was completely was compared to surgical femoropopliteal bypass removed (remote endarterectomy). Regarding procedures and percutaneous stenting in our hospital postoperative, result was evaluated as mentioned over the same study period regarding the following above. In 5 patients the lesion was limited to the end points: perioperative death, unrelated death, upper 2/3 of the SFA. The endarterectomy was myocardial infarction (MI), limb loss and repeat performed antegrade through the proximal procedures. (Table II). arteriotomy at the origin of the SFA.

In 6 patients a longitudinal arteriotomy at the common femoral artery was made for CFA Discussion endarterectomy to provide adequate inflow. In one Atherosclerotic arterial disease of the lower patient, SFA remote endarterectomy was performed extremities is a common event especially after the in association with an Aortobifemoral bypass. age of 55. The prevalence of intermittent During the postoperative period in the hospital claudication as one of its major manifestations (average 3-4 days), the patients received varied widely in population studies.(2) The most

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commonly affected artery is the SFA. SFA is lumen after remote endarterectomy is generally in affected in 70% of all patients with intermittent the range of 130% to 150% of the lumen size of the claudication.(3) The management of patients with original vessel, providing for a large margin of SFA disease includes a wide array of different safety and redundancy in the face of Rest-enosis.(9,10) specialties such as angiology, interventional Rest-enosis can occur in these endarterectomized radiology and vascular surgery.(3,5) segments but usually focally. These focal areas can Thromboendarterectomy was the procedure of be discovered through routine ultrasound choice for patients with peripheral vascular surveillance and treated by percutaneous dilatation occlusive disease. With gradual introduction of and stenting.(1,6,7) Moreover, endarterectomy spares femoropopliteal bypass, the bypass technique has the saphenous vein and avoids the use of synthetic gained predominance.(2,6,7) The advent of and the material. In case of femoral artery reocclusion, it development of prosthetic grafts led to a marked leaves the possibility to perform at a later time the decline in the number of surgeons performing the bypass technique.(2,8) Our own experience, despite thromboendarterectomy technique. In 1963, Jorg the low number of cases and limited follow-up time, Vollmar introduced the semi-closed endarterectomy confirms that the procedure of ring stripper as a minimally invasive surgical procedure using a endarterectomy (semiclosed and remote ring stripper. With the more recent development of endarterectomy) is an alternative procedure in endovascular stenting and atherectomy, revascularization of the obliterated SFA. A endarterectomy as a primary procedure in the modification of the ring stripper is the Mollring treatment of lower extremity ischemic disease has cutter introduced by Ho and Moll in 1995 (Fig.4). been indicated less frequently. The critical features This device enables the surgeon to perform the that make endarterectomy feasible are the endarterectomy through a small inguinal incision characteristic localization of atherosclerotic plaques (remote endarterectomy RE) (Fig 2). This is a to the intima and subjacent media of the diseased minimally invasive procedure which allows artery. The outer media and adventitia are spared by complete debulking and sharp cutting of the arterial atherosclerosis; therefore, a cleavage plane can be plaque distally followed by endoluminal stent developed between the diseased and nondiseased positioning at the distal intimal flap.(1,2,8) This zones of the arterial wall. This cleavage plane is intimal core is transversely cut at the SFA origin and characterized by easy separation between the two threaded into the loop of a conventional (Vollmar) zones. The inner thrombogenic layer is removed and ring stripper. The ring stripper is advanced distally the outer layer of the media (external elastic down the SFA beyond the occluded segment, the membrane) and adventitia are spared.(6) The residual location of which has been determined with outer media and adventitia left after endarterectomy intraoperative arteriography and “road mapping.” have sufficient tensile strength to support the vessel The ring stripper is exchanged for the Mollring wall. The presence of aneurysmal disease is the Cutter device, which transects the distal major specific and absolute contraindication to atheromatous core under fluoroscopic guidance. The endarterectomy for the management of occlusive entire core is removed, and arteriography is arterial disease.(6) Recently there has been a performed to confirm a patent distal artery. (1,2,6,7,11) reappraisal of endarterectomy. Several reports have Our clinical success rate was comparable to the shown it to have long-term patency comparable to results obtained at Department of Vascular Surgery femoropopliteal bypass surgery. Endarterectomy has And Interventional Radiology, St. Antonius a better patency than angioplasty in long segmental Hospital, Nieuwegein, Netherlands which achieved occlusive lesions and proves to be more cost a 96% clinical success rate in 26 patients over 6 effective.(1,5,6,7,8) Semiclosed and remote months. endarterectomy offers an autogenous revascularization technique that removes essentially all of the atherosclerotic material in the affected Conclusion vessel. As opposed to atherectomy, which removes Semiclosed and remote endarterectomy using ring less amounts of the plaque, this technique removes stripper is a useful technique in the treatment of virtually all the disease. As a result of the dilatation occlusive arterial lesions of the superficial femoral that vessels undergo in response to the initial stages artery. In our department it has an outcome of atherosclerotic occlusion (i.e. adaptation), the comparable to international centers and should be

66 JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 19 No. 1 March 2012 considered as one of the armamentarium used to 6. Rosenthal D, Schubart PJ, Kinney EV, et al. treat patients with arterial occlusive disease. Remote superficial femoral artery endarterectomy: multicenter medium-term results. J Vasc Surg 2001; 34:428-432. References 7. van der Heijden FH, Eikelboom BC, Reedt 1. Rosenthal D, Wellons ED, Burkett AB. Remote Dortland RW, et al. Long-term results of endarterectomy: This minimally invasive procedure semiclosed endarterectomy of the superficial is a viable treatment option for many patients with femoral artery and the outcome of failed peripheral vascular disease. Endovascular Today reconstructions. J Vasc Surg 1993; 18:271-9. October 2008. 8. Gwan H Frans, Moll, Paul, et al. The Mollring 2. LovriËeviÊ I, TonkoviÊ V, De Syo Drago, et al. cutter remote endarterectomy: Preliminary Remote endarterectomy with endoluminal stent experience with a new endovascular technique for implantation: an alternative procedure in treatment of occlusive SFA disease. J endovascular revascularization of obliterated femoral artery, Acta 1995; 2:278-287 clin Croat, 2001; 40(2):99-102. 9. Glagov S, Weisenberg E, Zarins CK, et al. 3. Gisbertz SS, Ramzan M, Tutein Nolthenius RP, Compensatory enlargement of human et al. Short-term results of a randomized trial atherosclerotic coronary arteries. N Engl J Med comparing remote endarterectomy and 1987; 316:1371. supragenicular bypass surgery for long occlusions 10. Ho GH, van Buren PA, Moll FL, et al. of the superficial femoral artery [the REVAS trial] Incidence, time-of-onset, and anatomical Eur J Vasc Endovasc Surg. 2009; 37:68-76 distribution of recurrent stenoses after remote 4. Shionoya S, Ban I, Nakata Y, et al. Involvement endarterectomy in superficial femoral artery of the iliac artery in Buerger’s disease occlusive disease. J Vasc Surg 1999; 30: 106- (pathogenesis and arterial reconstruction). J 113. Cardiovasc Surg (Torino) 1978; 19:69-76. 11. Teijink JA, van den Berg JC, Moll FL. A 5. Karkos D, Karamanos DG, Papadimitriou DN, minimally invasive technique in occlusive disease et al. Current Therapeutic Options in the of the superficial femoral artery: remote Management of Superficial Femoral Artery endarterectomy using the Mollring Cutter. Ann Occlusive Disease. Acta Chir Belg 2007; 107: 605- Vasc Surg 2001; 15:594-598. 615.

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