Revascularization for the Patients with Common Femoral Artery Occlusive Lesion

Abstract

Endovascular treatment (EVT) is now performed worldwide for patients with lower extremity artery disease due to its safety and advances in devices. However, a common femoral artery (CFA) lesion often has severe calcification, and balloon angioplasty alone for such a lesion is ineffective in terms of patency. EVT with stent implantation for a CFA lesion may result in stent fracture and difficulty with puncture for subsequent interventions during the follow-up period. Given these issues, endarterectomy for a CFA lesion remains as the gold standard treatment in the endovascular era. However, the method of endarterectomy (i.e., arterial incision, patch use or not, patch material, intimal layer fixation or not) differs among centers. Thus, further investigation is needed for each method to promote the performance of high-quality CFA endarterectomy by vascular surgeons in the current endovascular era. (This is a translation of Jpn J Vasc Surg 2024; 33: 91–95.)

Introduction

Treatment for peripheral artery disease has entered an era dominated by endovascular treatment (EVT). In particular, in the iliac artery and superficial femoral artery (SFA) lesions, EVT has often become the first-line treatment owing to its minimally invasive nature and device advancements that enable acceptable patency rates.^1–4) However, although the usefulness of EVT for common femoral artery (CFA) lesions has been reported, many skeptical views remain, and surgical endarterectomy is still widely performed. Based on various guidelines and previous reports, this article describes the usefulness of endarterectomy and hybrid treatment combining endarterectomy and EVT for CFA lesions and complex lesions involving the CFA.

I. Treatment Selection for CFA Lesions

According to the Global Vascular Guidelines (GVG 2019) by the Society for Vascular Surgery and the European Society for Vascular Surgery, endarterectomy for CFA lesions is considered the optimal treatment because of its minimally invasive nature and favorable long-term patency.¹⁾ In Japan as well, the revised peripheral arterial disease guidelines published in 2022 designate surgical endarterectomy as the first-line treatment for CFA lesions.²⁾ However, the only randomized controlled trial (RCT) comparing endarterectomy and EVT with stent placement for CFA lesions reported that EVT was superior in perioperative safety and equivalent in efficacy, including 2-year patency.⁵⁾ In this RCT, the 2-year primary patency rate of surgical endarterectomy was 82%. Generally, the patency of surgical endarterectomy for CFA lesions is extremely favorable. A multicenter retrospective study in Japan reported a 5-year patency rate of 100% in claudication cases and >90% even in cases with chronic limb-threatening ischemia, which is superior to the RCT findings.⁶⁾ Therefore, this RCT alone cannot conclude that EVT and surgical endarterectomy are equivalent for CFA lesions.

The 1-year follow-up results of the CAULIFLOWER (Common Femoral Artery Revascularization; Investigation of the Best Strategy from The Multicenter Retrospective Real-World Registry) study were reported in 2022. This study involved 66 institutions nationwide and evaluated 761 EVT and 432 surgical endarterectomy cases for CFA lesions. The 1-year primary patency rate was 97% for endarterectomy and 82% for EVT, demonstrating significantly better outcomes with endarterectomy.⁷⁾ Even today, in an era dominated by EVT, surgical endarterectomy may remain the first-line treatment for CFA lesions.

II. Annual Trends of Endarterectomy in Japan

Figure 1 shows the annual endarterectomy trends in Japan.^8–15) The number of procedures was 1040 in 2016, 1205 in 2017, and 1159 in 2018, remaining consistently above approximately 1000 cases per year.^13–15)

Fig. 1. Annual trends of infrainguinal surgical revascularization for patients with lower extremity artery disease in Japan. AK FP: above-the-knee femoropopliteal bypass; BK FP: below-the-knee femoropopliteal bypass; TEA: thromboendoarterectomy.

III. Details of Endarterectomy

1. Incision technique

CFA endarterectomy is performed using 2 techniques: the standard longitudinal incision technique and the eversion technique using a transverse incision. The eversion technique can be performed without a patch and shortens the incision length, operative time, and blood loss.¹⁶⁾ However, CFA lesions are rarely isolated. In cases with continuous lesions extending from the external iliac artery or involving the SFA or deep femoral artery (DFA), the standard technique that allows the incision to be extended is advantageous and is used worldwide. Thus, the indication for the eversion technique may be limited.

2. DFA reconstruction

The DFA is the lifeline of collateral circulation in the lower limb and becomes an important collateral pathway when atherosclerosis in the SFA lesion progresses in the future.

Therefore, when CFA lesions are accompanied by stenosis or occlusion at the DFA ostium, DFA endarterectomy must be performed simultaneously. The above-mentioned Japanese revised peripheral arterial disease guidelines also recommend the additional DFA endarterectomy for continuous lesions involving the DFA origin.²⁾ A meta-analysis of endarterectomy reported that DFA reconstruction was performed in 56% of cases. This indicates that concomitant lesions of the DFA origin are common in CFA disease and that DFA reconstruction should always be performed in such cases.¹⁷⁾

3. Closure of the incision

In Japan, primary closure and patch angioplasty with an autologous vein or prosthetic graft have traditionally been used to close the arteriotomy following endarterectomy. The advantages of primary closure include shorter operative time, avoidance of foreign material, and reduced risk of postoperative surgical site infection due to shorter incision length. However, the lack of patch enlargement may raise concerns regarding late luminal narrowing (Fig. 2). Patch angioplasty allows the maintenance of a larger arterial lumen at the endarterectomy site; however, vein patches may increase incision length and wound infection risk, whereas prosthetic patches carry a risk of graft infection. An analysis of 1930 CFA endarterectomy cases showed that 72% of patients underwent patch angioplasty, indicating that patch closure is the mainstream approach.¹⁷⁾ Nevertheless, both techniques have advantages and disadvantages, and comparative studies on the femoral artery region are limited. In carotid endarterectomy, many studies have shown that patch angioplasty has better long-term outcomes, including patency.¹⁸⁾ A subanalysis of the CAULIFLOWER study showed that patch angioplasty had significantly higher 2-year primary patency and freedom from target vessel revascularization than primary closure.¹⁹⁾

Fig. 2. Restenosis of the common femoral artery after endarterectomy with primary closure.

In 2020, a bovine pericardial patch (Xenosure; LeMaitre Vascular, Burlington, MA, USA) (Fig. 3) became commercially available in Japan for closure after common femoral endarterectomy.^20,21) Comparative studies have shown that vein patches and bovine pericardial patches have comparable 1-year patency rates.²¹⁾ Although bovine pericardial patches shorten the operative time by eliminating the need for vein harvest, they remain as foreign materials and pose infection concerns. With the availability of multiple patch materials, further detailed evaluation is required to determine the optimal closure method.

Fig. 3. Endarterectomy with bovine pericardium patch angioplasty.

4. Intimal fixation

There is no consensus on whether proximal or distal intimal fixation should be performed after endarterectomy. In the CAULIFLOWER study, distal intimal fixation was performed in 66% of the cases, suggesting that it is a more common practice.⁷⁾ Although distal fixation may prevent distal arterial occlusion caused by dissection progression (Fig. 4), further comparative studies are required.

Fig. 4. Acute occlusion of the superficial femoral artery four days after endarterectomy without intimal layer fixation at the distal site.

5. Late puncture

The CFA is the most commonly used EVT access site. When stents are placed in the CFA, future endovascular access through the CFA becomes difficult. An advantage of CFA endarterectomy is the ability to puncture the same site at a later time to perform EVT for other lesions. The outcomes have been reported in Japan.²²⁾ Although the safe timing of puncture after endarterectomy remains unclear, securing future access site is currently a significant benefit of endovascular therapy.

6. Selection of treatment for complex lesions

The GVG 2019,¹⁾ the revised 2022 Japanese peripheral arterial disease guidelines,²⁾ and the European Society of Cardiology guidelines³⁾ recommend hybrid treatment for CFA lesions accompanied by iliac or SFA lesions. This approach involves CFA endarterectomy combined with EVT for other lesions. As the outcomes of EVT for iliac and SFA lesions have improved, hybrid treatment has become a standard strategy.²³⁾ However, EVT outcomes remain suboptimal for SFA lesions with long-segment occlusion, severe calcification, small vessel diameter, or poor runoff. In such cases, bypass surgery using the endarterectomy site as the inflow site should be considered.

Conclusion

Surgical endarterectomy remains the first-line treatment for CFA lesions even today, despite the dominance of endovascular therapy. However, as EVT outcomes continue to improve, vascular surgeons must strive to perform higher-quality endarterectomy without complacency.

Declarations

Ethics approval

The content of this review was approved by the Hiroshima General Hospital Research Ethics Committee (Approval No. 23-81).

Author contributions

Study conception: TK

Data collection: TK

Analysis: TK

Investigation: TK

Manuscript preparation: TK

Critical review and revision: TK

Final approval of the article: TK

Accountability for all aspects of the work: TK.

Disclosure statement

The author declares no conflicts of interest.