Overview
Definition:
Endarterectomy of the profunda femoris artery is a surgical procedure to remove atherosclerotic plaque from the profunda femoris artery (also known as the deep femoral artery)
This artery is a major vessel supplying the thigh muscles and is crucial for maintaining blood flow to the distal lower limb, especially when the superficial femoral artery (SFA) is occluded.
Epidemiology:
Atherosclerotic disease affecting the profunda femoris artery is common, particularly in patients with infrainguinal peripheral artery disease (PAD)
It often coexists with SFA and popliteal artery occlusive disease
The incidence increases with age, diabetes mellitus, smoking, hypertension, and hyperlipidemia.
Clinical Significance:
Preserving or restoring profunda femoris artery flow is vital for limb salvage, particularly in patients with critical limb ischemia (CLI)
The profunda femoris artery supplies a significant portion of the thigh musculature, which plays a role in distal perfusion through collateral pathways and the angiosome concept
Endarterectomy can be an alternative to bypass surgery in select cases, offering a durable solution.
Indications
Indications For Procedure:
Significant stenosis or occlusion of the profunda femoris artery causing symptoms of PAD, especially when the SFA is not suitable for bypass or endovascular intervention
Critical limb ischemia (CLI) with rest pain, ischemic ulcers, or gangrene
Claudication symptoms not responsive to conservative management
Patients with a healthy profunda femoris artery amenable to direct reconstruction as a sole inflow source.
Contraindications:
Unreconstructable distal arterial tree
Extensive calcification of the profunda femoris artery making endarterectomy technically challenging
Severe systemic illness precluding major surgery
Active infection at the surgical site
Absence of palpable distal pulses and no collateral circulation
End stage renal disease with poor prognosis.
Preoperative Preparation
Patient Evaluation:
Comprehensive history and physical examination focusing on cardiovascular risk factors and symptoms of PAD
Assessment of ankle-brachial index (ABI) and toe-brachial index (TBI)
Detailed neurological and dermatological examination of the affected limb.
Diagnostic Imaging:
Duplex ultrasound to assess the extent and severity of profunda femoris artery disease and inflow to the SFA
Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) for detailed anatomical mapping of the arterial tree
Conventional angiography if endovascular options are being considered or to confirm duplex findings.
Medical Optimization:
Aggressive management of comorbidities: diabetes control (HbA1c < 7%), hypertension control (BP < 140/90 mmHg), smoking cessation counseling
Antithrombotic therapy with aspirin and/or clopidogrel initiated preoperatively
Optimization of cardiac and pulmonary function
Preoperative antibiotics according to hospital protocol.
Procedure Steps
Surgical Approach:
A longitudinal incision is made over the CFA and proximal profunda femoris artery, typically in the groin crease
The common femoral artery (CFA) and superficial femoral artery (SFA) are exposed
The origin of the profunda femoris artery is identified.
Arterial Exposure And Control:
The CFA and proximal profunda femoris artery are dissected and controlled with vessel loops or vascular clamps
Heparinization is administered
An arteriotomy is made in the CFA or proximal profunda femoris artery to gain access.
Endarterectomy Technique:
An incision is made at the origin of the profunda femoris artery
Dissection is performed between the atheromatous plaque and the arterial intima using specialized endarterectomy instruments
The dissection plane is meticulously maintained to avoid intimal injury or perforation
The plane is carried distally to the desired limit or until healthy artery is encountered
The plaque is removed as a single core or in segments.
Closure And Completion:
The arteriotomy is closed primarily with a running monofilament suture, or a patch angioplasty (e.g., autologous saphenous vein or synthetic patch) may be used to widen the lumen and reduce the risk of stenosis
Flow is restored after systemic heparin reversal
Distal pulses are checked
Hemostasis is achieved
The wound is closed in layers.
Postoperative Care
Immediate Monitoring:
Close monitoring of vital signs, urine output, and fluid balance
Frequent assessment of distal pulses and limb perfusion
Pain management with analgesics
Application of warm blankets
Monitoring for bleeding at the surgical site.
Antithrombotic Therapy:
Continued administration of aspirin (e.g., 81-325 mg daily) and/or clopidogrel (e.g., 75 mg daily) for at least 6-12 months, or indefinitely in high-risk patients, to prevent graft thrombosis or restenosis
Enoxaparin may be used for initial anticoagulation if indicated.
Ambulation And Rehabilitation:
Early ambulation is encouraged to improve circulation and prevent deep vein thrombosis (DVT)
Gradual increase in physical activity
Referral to vascular rehabilitation program if available
Education on wound care and lifestyle modifications.
Follow Up Schedule:
Regular follow-up appointments with vascular surgery clinic
Clinical assessment and non-invasive vascular studies (e.g., duplex ultrasound) at 1, 3, 6, 12 months and annually thereafter, or as clinically indicated, to monitor for restenosis or occlusion.
Complications
Early Complications:
Hemorrhage from the arteriotomy site or dissection plane
Pseudoaneurysm formation at the repair site
Distal embolization leading to limb ischemia or other organ infarction
Wound infection
Deep vein thrombosis (DVT) or pulmonary embolism (PE)
Nerve injury causing sensory or motor deficits.
Late Complications:
Restenosis or occlusion of the repaired profunda femoris artery
Chronic wound healing problems
Graft failure if a patch was used
Progression of disease in other arterial segments
Incisional hernia.
Prevention Strategies:
Meticulous surgical technique to achieve adequate lumen reconstruction and smooth intimal surface
Careful plaque removal to avoid intimal flap
Appropriate use of patch angioplasty if needed
Strict adherence to postoperative antithrombotic therapy
Aggressive management of risk factors
Careful patient selection.
Prognosis
Factors Affecting Prognosis:
Severity of infrainguinal PAD
Presence of comorbidities (diabetes, renal failure, CAD)
Technical success of the endarterectomy
Adequacy of distal revascularization
Patient compliance with medical therapy and lifestyle modifications.
Outcomes:
Successful profunda femoris endarterectomy can lead to significant improvement in claudication symptoms and limb salvage in patients with CLI
Long-term patency rates vary but can be comparable to bypass in select cases
Survival rates are largely determined by the patient's overall cardiovascular health.
Alternatives And Comparisons:
Comparison with femoropopliteal bypass grafting: endarterectomy may offer better long-term patency in cases of isolated profunda femoris disease or when the SFA is unsuitable for bypass
Endovascular angioplasty and stenting of the profunda femoris artery is an alternative for less complex lesions but may have lower long-term durability compared to open surgery for extensive disease.
Key Points
Exam Focus:
Profunda femoris artery supplies thigh muscles and is key for limb salvage in infrainguinal PAD
Endarterectomy is indicated for severe stenosis/occlusion, especially with CLI and unsuitable SFA
Technical success relies on meticulous plaque removal and adequate closure (primary or patch angioplasty)
Postoperative antithrombotic therapy is crucial.
Clinical Pearls:
In patients with critical limb ischemia and occluded SFA, a patent profunda femoris artery is a lifeline
Always check profunda femoris artery flow intraoperatively
Use Doppler to confirm satisfactory flow post-closure
Patch angioplasty can reduce restenosis risk after endarterectomy.
Common Mistakes:
Incomplete plaque removal leading to edge dissections or intimal flaps
Injury to the profunda femoris artery lumen during dissection
Inadequate outflow assessment
Insufficient antithrombotic therapy postoperatively
Overlooking concurrent SFA or distal occlusive disease.