Femoral Endarterectomy against Iliofemoral bypass-Case Series

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Thedecision for an ideal vascular procedure for occlusive peripheral arterial disease depends on type of lesion involved, patient factors and the options available to deal with it. Despite a dramatic increase in the use of endovascular techniques to treat chronic limb ischemia secondary to femoral arterial disease (FAD), femoral endarterectomy (FE) and profundaplasty remain the procedures of choice because long-term patency results are still superior to any other intervention. The American Heart Association  has recommended that angioplasty of the femoral artery be carried out only in single lesions of less than 10 cm, and better results are associated with short lesion length and good runoff, claudication, stenosis and the absence of diabetes. The immediate placement of a stent after angioplasty may address the issues of elastic recoil and dissections and improve the early success rate, but it has not been shown consistently to improve long-term patency. Even though the endarterectomy was the one of the first described procedures, autogenous long saphenous vein bypass has surpassed it as the preferred procedure for occlusive disease in the infrainguinal region. This is largely the result of several series reporting an inferior long term patency rate with endarterectomy. Further studies were conducted to compare the efficacy of available surgical options (vein by-pass, open endarterectomy and semi-closed endarterectomy) to combat the femoro-popliteal occlusion and it showed that the immediate failures and late cumulative patency/survival were similar for all three procedures. Studies supported the use of endarterectomy as available option for infrainguinal arterial diseases with very comparable results to vein grafts.

The longsaphenous vein is a very demanding conduit if coronary or vein bypass is required in future. Synthetic grafts and angioplasty studies has shown inferior results (high early and late restenosis rates). The present retrospective study is to evaluate the results of open endarterectomy in short atherosclerotic occlusion of the femoral artery against iliofemoral bypass grafting with long saphenous vein graft. Endarterectomy of localized lesions of the iliofemoral artery was performed in 5 male patients between May 2013 and May 2015, with a proven diagnosis of chronic occlusion of isolated external iliac artery or iliofemoral artery. The diagnosis was confirmed by angiography. The median age of the patients was 40 +/− 10 years. Risk factors for peripheral atherosclerosis were diabetes, electrocardiogram changes of past myocardial is chaemia, smoking and hypertension.

All patients suffered from atherosclerosis, and had thrombosis or stenosis of the external iliac artery associated with/without adjoining femoral artery and profunda femoris artery. All endarterectomies were performed as a primary procedure and not as an adjunct to a bypass procedure. Selection of patients the indications for operation in this series were disabling intermittent claudication, rest pain and gangrene. Out of five in two cases, the claudication distance was 100m or less and in two cases had rest pain severe enough to interfere with sleep and one case had established gangrene of the toes. In those with occlusive disease localized to the iliofemoral artery, the patient’s usually had with no pulses in the limb distally on the affected side. Occasion-ally, weak pedal pulses were present. All patients were investigated by Colour Doppler scan by CE FDA 3D 4D Doppler ultrasound and femoral angiography. Where unequal femoral pulses were present, or bruits were audible over the iliac or common femoral vessels, suggesting more proximal lesions, lumbar orthography was performed and if present these patients were excluded from the study.