Overview
Definition:
Iliofemoral endarterectomy with patch angioplasty is a surgical procedure to remove atherosclerotic plaque from the iliac and femoral arteries, followed by reconstruction of the artery using a patch to widen its diameter.
Epidemiology:
Atherosclerotic disease affecting the aortoiliac and common femoral arteries is a significant cause of peripheral artery disease (PAD)
It is more prevalent in older adults, males, smokers, diabetics, and individuals with hypertension and hyperlipidemia.
Clinical Significance:
This procedure is crucial for restoring blood flow to the lower extremities in patients with severe aortoiliac or common femoral artery occlusive disease, thereby alleviating symptoms of claudication and preventing limb-threatening ischemia
It is a vital surgical option for managing advanced PAD and improving patient quality of life, making it a key topic for surgical residents preparing for examinations.
Indications
Symptomatic Disease:
Patients with disabling intermittent claudication affecting daily activities
Rest pain or ischemic ulcers, and gangrene in the lower extremities (critical limb ischemia).
Angiographic Findings:
Significant stenosis (typically >70%) or occlusion of the common iliac, external iliac, or common femoral arteries
Absence of suitable distal targets for bypass, or failure of endovascular intervention.
Patient Factors:
Suitability for major surgery
Absence of contraindications like severe comorbidities that preclude successful recovery.
Preoperative Preparation
Patient Evaluation:
Detailed medical history focusing on cardiovascular risk factors, PAD symptoms, and comorbidities
Comprehensive physical examination including pulse assessment in all lower extremity arteries.
Diagnostic Imaging:
Arteriography of the aorta and lower extremities to delineate the extent and severity of disease, identify patent runoff vessels, and assess suitability for endarterectomy
Non-invasive vascular studies like duplex ultrasound and ankle-brachial index (ABI) are also important.
Risk Assessment:
Cardiopulmonary assessment, renal function tests, and electrolyte balance
Optimization of medical conditions like diabetes, hypertension, and dyslipidemia.
Consent And Anesthesia:
Informed consent explaining the procedure, risks, benefits, and alternatives
Anesthesia choice is typically general or regional (spinal/epidural).
Procedure Steps
Arterial Exposure:
Surgical approach involves an incision typically in the lower abdomen and groin (e.g., midline laparotomy or retroperitoneal approach for iliac exposure, and a horizontal or oblique groin incision for femoral exposure).
Arterial Control:
Proximal and distal control of the involved iliofemoral arteries is achieved using vascular clamps after systemic heparinization.
Endarterectomy:
The diseased arterial segment is opened longitudinally
Atherosclerotic plaque is carefully dissected and removed from the artery wall, creating a smooth lumen down to healthy tissue.
Arterial Reconstruction:
The arteriotomy is closed using a synthetic patch (e.g., Dacron, PTFE) or autologous vein patch
The patch widens the artery, preventing suture line stenosis and improving flow
Careful meticulous suture technique is essential.
Completion Angiography:
Intraoperative completion angiography may be performed to assess the adequacy of the reconstruction, confirm patency, and identify any technical issues or residual stenoses.
Postoperative Care
Hemodynamic Monitoring:
Close monitoring of blood pressure, heart rate, and urine output
Management of fluid balance is critical.
Wound Care:
Meticulous wound care to prevent infection
Early mobilization to prevent deep vein thrombosis (DVT) and pulmonary embolism (PE).
Pain Management:
Adequate pain control using analgesics.
Antithrombotic Therapy:
Initiation of antiplatelet therapy (e.g., aspirin, clopidogrel) to maintain graft patency and prevent thrombus formation
Anticoagulation may be used in selected cases.
Follow Up Protocol:
Regular clinical assessment and non-invasive vascular studies (e.g., duplex ultrasound) at regular intervals to monitor the integrity of the repair and the patency of the reconstructed arteries.
Complications
Early Complications:
Hemorrhage from suture lines or the endarterectomy site
Thrombosis of the reconstructed segment
Infection of the wound or graft
Limb ischemia due to distal embolization or graft failure
Nerve injury.
Late Complications:
Restenosis at the suture line or within the patch angioplasty
Pseudoaneurysm formation
Distal embolization
Late graft infection
Chronic limb-threatening ischemia due to graft failure.
Prevention Strategies:
Meticulous surgical technique, adequate heparinization, use of appropriate prosthetic material, thorough flush of the artery before closure, aggressive postoperative antithrombotic therapy, and vigilant long-term follow-up.
Prognosis
Factors Affecting Prognosis:
Extent and severity of atherosclerotic disease
Presence of comorbidities
Quality of runoff vessels
Technical success of the procedure
Adherence to postoperative medical management and follow-up.
Outcomes:
Successful iliofemoral endarterectomy with patch angioplasty can provide excellent long-term patency rates and significant relief of symptoms, leading to improved limb salvage and quality of life
Patency rates can be as high as 85-90% at 5 years with optimal management.
Follow Up:
Lifelong follow-up is recommended
This includes regular clinical examinations and non-invasive vascular testing to detect early signs of restenosis or graft failure, allowing for timely intervention.
Key Points
Exam Focus:
Indications for endarterectomy versus bypass
Key steps in the surgical technique
Management of early and late complications
Importance of patch angioplasty in preventing suture-line stenosis
Postoperative antithrombotic therapy protocols.
Clinical Pearls:
Aggressively identify and treat PAD risk factors
Emphasize meticulous plaque removal to the adventitia
Careful consideration of patch material and size
Early mobilization and vigilant wound care are paramount.
Common Mistakes:
Incomplete plaque removal leading to restenosis
Inadequate distal control
Use of too small a patch leading to stenosis
Over-reliance on heparin without adequate antiplatelet therapy post-op
Neglecting regular follow-up.