Management of Flush Superficial Femoral Artery Occlusions with Combined Open Femoral Endarterectomy and Endovascular Femoral-Popliteal Angioplasty and Stenting

OBJECTIVES: Flush occlusions of the superficial femoral artery (SFA) often preclude endovascular interventions due to an inability to gain wire access in the absence of an SFA stump. For appropriate patients, we have adopted a technique of revascularization through a single, small groin incision by combining femoral endarterectomy with distal femoral-popliteal endovascular stenting, and we describe our technique and results in 14 consecutive patients.
METHODS: 14 patients were identified from our prospectively gathered registry from May 2005 to April 2009. Data on indications, complications, length of hospital stay, pre- and post- ankle brachial indices (ABIs), patency, limb salvage and functional results were collected.
RESULTS: Of the 14 patients, 9 were operated on for disabling claudication, 2 for rest pain, and 3 for tissue loss. The median ABI of the affected leg pre-operatively was 0.61 before surgery and 0.99 after surgery. The only complications were three minor wound complications, all of which healed with conservative wound care treatment. The average length of stay was 5 days. 1 patient died secondary to unrelated causes 5 months after the procedure, 2 patients did not return for follow-up after discharge and 3 others were lost to follow-up after primary patency was confirmed at 2, 4, and 4 months, respectively. Of the remaining 8 patients, 4 still have primary patency of their stent grafts at 52, 19, 17 and 4 months, respectively, and a fifth patient has secondary patency at 24 months. The remaining 3 patients occluded their stent grafts with primary patency last confirmed at 0.5, 2.5 and 8 months, respectively; two have stable claudication and one has a non-healing wound and rest pain, but all have limb salvage to date.
CONCLUSIONS: Combined femoral endarterectomy and endovascular femoral-popliteal stent grafting provides a viable option for revascularization of flush SFA occlusions with only a minimal groin incision. Results of this technique compare favorably with femoral-distal bypass, and further studies directly comparing them are warranted.