Overview
Definition:
Common femoral artery (CFA) endarterectomy is a surgical procedure to remove atherosclerotic plaque from the inner lining (endothelium) of the common femoral artery
This procedure aims to restore blood flow to the lower extremities by clearing obstructions caused by atherosclerosis.
Epidemiology:
Atherosclerosis of the common femoral artery is a common manifestation of peripheral artery disease (PAD), affecting a significant portion of the elderly population, particularly those with risk factors like diabetes, hypertension, smoking, and hyperlipidemia
Prevalence increases with age, affecting up to 20% of individuals over 70 years old.
Clinical Significance:
Significant stenosis or occlusion of the CFA can lead to critical limb ischemia (CLI), characterized by rest pain, non-healing ulcers, and gangrene
Endarterectomy is a crucial revascularization technique for selected patients, offering an alternative to bypass grafting, and plays a vital role in limb salvage and improving quality of life.
Indications
Indications For Surgery:
Significant stenosis (>50-75%) or occlusion of the common femoral artery causing symptomatic PAD
Critical limb ischemia with rest pain, non-healing ulcers, or gangrene
Claudication not responding to medical management
Facilitation of distal bypass procedures when direct distal anastomosis is not feasible
Presence of extensive CFA disease without suitable proximal inflow for bypass
Absence of suitable distal targets for bypass grafting.
Contraindications:
Severe comorbidities precluding major surgery
Life expectancy less than 2 years
Sepsis or active infection in the limb
Absence of distal runoff vessels
Extensive diffuse disease of the CFA and profunda femoris artery that would preclude adequate flow restoration
Previous extensive surgery or radiation to the groin area.
Patient Selection:
Careful assessment of the patient's overall health status, comorbidities, and life expectancy is paramount
Ankle-brachial index (ABI) and Doppler ultrasound are essential for assessing the severity of PAD
Angiography is crucial for defining the extent of disease and identifying suitable distal outflow
The feasibility of endarterectomy versus bypass grafting is determined by the morphology of the plaque and the condition of the profunda femoris artery.
Preoperative Preparation
Preoperative Evaluation:
Comprehensive medical history and physical examination focusing on cardiovascular, respiratory, and renal systems
Laboratory investigations including complete blood count, electrolytes, renal function tests, coagulation profile, and electrocardiogram
Risk stratification for perioperative complications using scoring systems like the Revised Cardiac Risk Index.
Imaging Studies:
Duplex ultrasound is the primary non-invasive imaging modality to assess the anatomy and severity of CFA disease
Angiography (conventional or CT/MR angiography) is essential to delineate the extent of stenosis/occlusion, identify collateral circulation, and assess the profunda femoris artery and distal runoff vessels.
Anesthesia Considerations:
General anesthesia is typically employed, but spinal or epidural anesthesia may be considered in select patients with significant pulmonary disease
Adequate venous access and invasive hemodynamic monitoring may be necessary for high-risk patients
Prophylactic antibiotics are administered to reduce the risk of wound infection.
Procedure Steps
Surgical Approach:
A curvilinear incision is made over the common femoral artery in the groin, extending distally along the anterior thigh
The artery is carefully dissected free from surrounding tissues, identifying the superficial femoral artery, profunda femoris artery, and saphenous vein.
Arterial Exposure And Control:
The common femoral artery is then completely mobilized
Proximal and distal control of the common femoral artery is achieved using vascular clamps
Systemic heparinization is usually administered before clamping to prevent thrombus formation
An arteriotomy is made longitudinally over the area of stenosis or occlusion.
Endarterectomy Technique:
The atherosclerotic plaque is dissected from the arterial wall using specialized instruments
The plane of dissection should be between the plaque and the media to minimize arterial wall damage
The plaque is removed in its entirety from the lumen
Careful attention is paid to ensure a smooth transition between the removed plaque and the normal arterial wall to prevent intimal flaps or dissections.
Closure And Reconstruction:
After plaque removal, the arteriotomy is closed
In cases of significant arteriotomy, primary closure with a patch angioplasty (vein or synthetic) is preferred to prevent narrowing
The profunda femoris artery and superficial femoral artery are assessed for patency
Distal control is released, and flow is restored
The wound is then irrigated and closed in layers.
Postoperative Care
Immediate Postoperative Management:
Close monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation
Assessment of distal pulses and limb perfusion at regular intervals
Pain management with analgesics
Intravenous fluids and electrolyte balance monitoring
Anticoagulation may be continued if indicated.
Wound Care:
Sterile dressing changes and meticulous wound care to prevent infection
Monitoring for signs of wound dehiscence or hematoma
Early ambulation is encouraged as tolerated to prevent deep vein thrombosis (DVT).
Medications:
Aspirin is typically initiated or continued postoperatively to prevent graft thrombosis and intimal hyperplasia
Other antiplatelet agents or anticoagulants may be used depending on the individual patient's risk factors and the presence of any residual disease
Statins are prescribed to manage hyperlipidemia
Blood pressure control is essential.
Complications
Early Complications:
Hemorrhage from the arteriotomy site or surrounding tissues
Hematoma formation in the groin
Infection of the surgical wound or graft site
Distal embolization causing acute limb ischemia
Deep vein thrombosis
Arteriovenous fistula or pseudoaneurysm formation
Nerve injury leading to sensory or motor deficits
Graft occlusion.
Late Complications:
Restenosis due to intimal hyperplasia or progression of atherosclerosis
Chronic limb ischemia
Graft limb occlusion
Distal arterial disease progression
Chronic groin pain
Pseudoaneurysm recurrence
Infection of a synthetic patch.
Prevention Strategies:
Meticulous surgical technique to achieve a smooth intimal surface and avoid intimal flaps
Careful plaque removal to prevent arterial wall damage
Adequate wound closure and hemostasis
Use of prophylactic antibiotics
Early ambulation and DVT prophylaxis
Long-term antiplatelet therapy
Aggressive management of risk factors including smoking cessation and control of diabetes, hypertension, and hyperlipidemia.
Prognosis
Factors Affecting Prognosis:
The success of CFA endarterectomy depends on the extent and severity of the atherosclerotic disease, the quality of distal runoff, the presence of comorbidities, and the technical success of the procedure
Patients with critical limb ischemia generally have a poorer prognosis compared to those with claudication.
Outcomes:
Successful endarterectomy typically leads to significant improvement in limb perfusion, relief of claudication symptoms, and healing of ischemic ulcers
Limb salvage rates are generally high, often exceeding 90% in appropriately selected patients
Long-term patency rates can be excellent, especially when combined with proper medical management of risk factors.
Follow Up:
Regular lifelong follow-up is crucial
This includes clinical assessment of symptoms and physical examination of pulses
Non-invasive vascular imaging, such as duplex ultrasound, is recommended at regular intervals (e.g., 1 month, 6 months, and then annually) to monitor for restenosis or graft occlusion
Aggressive management of cardiovascular risk factors should be continued.
Key Points
Exam Focus:
Understand the indications for CFA endarterectomy versus bypass grafting
Recognize the importance of the profunda femoris artery patency for successful outcomes
Recall the common early and late complications and their management
Be aware of the role of antiplatelet therapy in long-term patency.
Clinical Pearls:
A smooth, tapered closure of the arteriotomy or patch angioplasty is crucial for preventing restenosis
Distal embolization can be a significant complication
meticulous technique is vital
Always assess the profunda femoris artery for adequate outflow
Consider antegrade flush from the CFA to ensure distal flow before closing.
Common Mistakes:
Inadequate plaque removal leading to intimal flaps or residual stenosis
Overzealous dissection causing damage to the arterial wall or adjacent structures
Failure to adequately assess distal runoff
Incomplete closure of the arteriotomy leading to pseudoaneurysm formation
Inadequate medical management of risk factors leading to progression of disease.