Overview
Definition:
Patch angioplasty is a reconstructive surgical technique used to widen a narrowed or occluded artery, specifically applied after endarterectomy in the femoral artery
Endarterectomy involves surgically removing atherosclerotic plaque from the inner lining of an artery
Patch angioplasty is then performed to close the arteriotomy (incision) with a patch graft, preventing narrowing and restoring adequate blood flow.
Epidemiology:
Femoral artery disease is common, particularly in patients with risk factors for atherosclerosis
Endarterectomy is a well-established treatment for significant femoropopliteal occlusive disease, with patch angioplasty being a common method for arterial reconstruction post-procedure, especially for larger arteriotomies.
Clinical Significance:
Effective reconstruction after femoral endarterectomy is crucial to prevent restenosis and maintain long-term patency
Patch angioplasty helps achieve this by creating a wider lumen than simple primary closure, thereby reducing the risk of recurrence of symptoms and improving patient outcomes in limb salvage and claudication management.
Indications
Indications For Endarterectomy:
Symptomatic femoropopliteal arterial disease causing intermittent claudication, rest pain, or tissue loss
Non-healing ulcers or gangrene attributable to arterial insufficiency
Significant stenosis (>50-75%) or occlusion of the superficial femoral artery (SFA) on imaging.
Indications For Patch Angioplasty:
Large arteriotomy after femoral endarterectomy that would lead to significant narrowing if closed primarily
Tortuous vessels where primary closure may kink the artery
To achieve a wider, more favorable distal outflow reconstruction
When the quality of the surrounding arterial wall is compromised.
Contraindications:
Active infection at the surgical site
Severe systemic illness precluding major surgery
Inability to tolerate anesthesia
Distal embolization from the operative field
Extensive multilevel disease requiring bypass rather than endarterectomy.
Preoperative Preparation
History And Physical Exam:
Detailed history of claudication, rest pain, or ischemic changes
Assessment of risk factors: diabetes, hypertension, hyperlipidemia, smoking
Physical examination including pulse assessment (femoral, popliteal, pedal), capillary refill, skin temperature, and presence of ulcers or gangrene.
Diagnostic Imaging:
Ankle-brachial index (ABI) to assess severity
Duplex ultrasonography for initial assessment and to guide endarterectomy plane
Contrast angiography (conventional or CT/MR) to define the extent and location of disease, and to assess suitability for endarterectomy and the arteriotomy closure strategy.
Medical Optimization:
Management of comorbidities: glycemic control, blood pressure control, lipid-lowering therapy
Smoking cessation counseling
Preoperative antibiotics
DVT prophylaxis considerations.
Procedure Steps
Arteriotomy And Endarterectomy:
Incision over the superficial femoral artery
Exposure of the diseased segment
Longitudinal arteriotomy performed
Careful dissection and removal of atherosclerotic plaque from the artery wall, ensuring a smooth transition proximally and distally.
Patch Selection And Preparation:
Selection of patch material: autologous saphenous vein (most common), synthetic grafts (e.g., Dacron, PTFE), or bovine pericardium
The patch should be appropriately sized and shaped to close the arteriotomy defect without tension.
Patch Closure:
The prepared patch is sutured to the edges of the arteriotomy using fine, non-absorbable sutures (e.g., 5-0 or 6-0 polypropylene)
Suturing is typically performed in a continuous or interrupted fashion
The goal is to create a wide, spatulated opening
Ensuring adequate proximal and distal control of the artery is critical before and during closure.
Hemostasis And Completion:
Meticulous attention to hemostasis
The distal anastomosis of the endarterectomy segment is checked for smooth flow
The arteriotomy is flushed to remove any thrombus
The wound is closed in layers
Completion angiography or duplex ultrasound may be performed to confirm patency and exclude stenosis or pseudoaneurysm at the repair site.
Postoperative Care
Monitoring:
Close monitoring of vital signs and hemodynamic stability
Frequent assessment of limb perfusion, including pulse checks, skin temperature, and capillary refill
Pain management
Wound monitoring for bleeding or infection.
Medications:
Continued DVT prophylaxis
Appropriate analgesia
Antiplatelet therapy (e.g., aspirin, clopidogrel) is crucial to maintain graft patency and prevent thrombosis
Antibiotics as per hospital protocol.
Activity And Mobilization:
Early mobilization as tolerated, often starting with ambulation the day after surgery
Gradual increase in activity levels
Advice on avoiding leg elevation beyond what is needed for venous return
Graduated compression stockings may be used in select cases.
Follow Up:
Regular clinical follow-up appointments
Non-invasive vascular studies (duplex ultrasound) at regular intervals (e.g., 1, 6, 12 months, then annually) to assess the patency of the repaired segment and to detect early signs of restenosis.
Complications
Early Complications:
Hemorrhage or hematoma at the surgical site
Infection of the wound or graft
Thrombosis of the repaired artery or patch
Distal embolization causing limb ischemia
Nerve injury leading to sensory or motor deficits
Pseudoaneurysm formation at the suture line.
Late Complications:
Restenosis of the repaired segment due to intimal hyperplasia or graft failure
Graft infection (especially with synthetic grafts)
Chronic limb ischemia recurrence
Development of new occlusive disease in adjacent segments.
Prevention Strategies:
Meticulous surgical technique to ensure smooth arterial reconstruction and prevent intimal flap
Adequate anticoagulation/antiplatelet therapy
Use of autologous vein grafts when possible
Prompt recognition and management of wound complications
Careful patient selection and optimization of risk factors.
Key Points
Exam Focus:
The primary goal of patch angioplasty after femoral endarterectomy is to prevent restenosis by widening the arterial lumen and avoiding tension at the suture line
Autologous saphenous vein is the preferred patch material due to its lower thrombogenicity and better long-term patency compared to synthetics
Completion angiography or duplex ultrasound is vital to assess the result.
Clinical Pearls:
Ensure a smooth transition from the endarterectomy plane to the native vessel wall to prevent intimal flaps
Suture the patch with adequate spatulation to create a wide lumen
Consider the use of a distal bypass graft in cases of severe distal disease or poor distal runoff, rather than relying solely on endarterectomy with patch closure.
Common Mistakes:
Inadequate plaque removal leading to intimal flaps
Overtight or too small a patch causing narrowing
Failure to adequately assess distal runoff
Insufficient perioperative antiplatelet therapy
Delayed diagnosis and management of early thrombotic occlusion or graft infection.