Overview
Definition:
Thromboendarterectomy is a surgical procedure to remove atherosclerotic plaque and thrombus from the inner lining of an artery, specifically the common femoral artery in this context
It aims to restore normal blood flow through the affected segment.
Epidemiology:
Peripheral artery disease (PAD) affects a significant portion of the population, particularly older adults and those with risk factors like diabetes, smoking, and hypertension
The common femoral artery is a common site for atherosclerotic involvement due to its bifurcating nature.
Clinical Significance:
Occlusion or stenosis of the common femoral artery significantly impairs blood supply to the lower extremities, leading to claudication, rest pain, and critical limb ischemia
Endarterectomy is a crucial intervention for limb salvage and improving quality of life in select patients, making it a vital topic for surgical residents.
Indications
Indications For Surgery:
Significant stenosis or occlusion of the common femoral artery causing symptoms of PAD
Claudication limiting daily activities
Rest pain
Non-healing ulcers
Gangrene requiring limb salvage
Absence of contraindications.
Patient Selection:
Careful patient selection is paramount
Patients should have a reasonable life expectancy to benefit from the procedure
Assessment of comorbidities and overall physiological status is essential
Adequate runoff from the profunda femoris artery is necessary for a successful outcome.
Contraindications:
Severe systemic illness making surgery high-risk
Extensive distal occlusive disease with poor runoff
Active infection at the surgical site
Limited life expectancy
Patient refusal or inability to comply with postoperative care.
Diagnostic Approach
History Taking:
Detailed history of claudication symptoms (location, duration, severity)
Rest pain
Non-healing wounds
Previous vascular interventions
Risk factor assessment: smoking, diabetes, hypertension, hyperlipidemia
Family history of vascular disease.
Physical Examination:
Palpation of peripheral pulses (femoral, popliteal, dorsalis pedis, posterior tibial)
Auscultation for bruits over the femoral artery
Assessment of limb perfusion: skin temperature, color, hair distribution, presence of ulcers or gangrene
Neurological assessment.
Investigations:
Ankle-brachial index (ABI) to quantify PAD severity
Duplex ultrasonography for non-invasive assessment of arterial anatomy, stenosis, and flow
Computed tomography angiography (CTA) or digital subtraction angiography (DSA) for detailed anatomical mapping and planning, essential for surgical approach.
Differential Diagnosis:
Other causes of leg pain: musculoskeletal disorders (arthritis, neuropathy), deep vein thrombosis, spinal stenosis, superficial thrombophlebitis
Differentiating arterial insufficiency from these conditions is critical.
Surgical Management
Preoperative Preparation:
Optimization of medical comorbidities: glycemic control, blood pressure management, smoking cessation counseling
Prophylactic antibiotics
Anesthesia assessment
Preoperative imaging review.
Anesthesia:
Typically performed under general anesthesia or regional anesthesia (spinal or epidural)
Monitored anesthesia care (MAC) may be used in select cases.
Procedure Steps:
Surgical approach: Incision over the common femoral artery and its bifurcation
Exposure and isolation of the CFA, superficial femoral artery (SFA), and profunda femoris artery (PFA)
Systemic heparinization
Application of vascular clamps
Incision into the CFA
Dissection of the atherosclerotic plaque from the artery wall using specialized instruments
Careful closure of the arteriotomy, often with a prosthetic patch angioplasty to widen the lumen and reduce restenosis risk
Release of clamps and meticulous hemostasis
Wound closure.
Alternative Techniques:
Balloon angioplasty and stenting can be considered for select cases, especially in patients with high surgical risk or specific anatomical limitations
However, endarterectomy offers a durable solution for significant CFA disease.
Postoperative Care
Immediate Postoperative Care:
Close monitoring of vital signs and limb perfusion
Pain management
Intravenous fluids
Anticoagulation as indicated
Early ambulation when safe.
Monitoring For Complications:
Watch for signs of bleeding, hematoma formation, wound infection, compartment syndrome, and new or worsening ischemic symptoms
Regular pulse checks and ABI measurements
Doppler assessment if needed.
Medical Management Postop:
Antiplatelet therapy (aspirin, clopidogrel) is crucial to prevent graft thrombosis and restenosis
Statins for lipid-lowering
Management of underlying risk factors: diabetes control, antihypertensive therapy, smoking cessation encouragement
Long-term anticoagulation may be considered in specific circumstances.
Complications
Early Complications:
Bleeding and hematoma formation at the surgical site
Wound infection
Distal embolization leading to acute limb ischemia
Nerve injury
Deep vein thrombosis
Myocardial infarction or stroke due to perioperative stress.
Late Complications:
Restenosis at the endarterectomy site, often due to intimal hyperplasia or residual plaque
Graft occlusion if a patch angioplasty was performed
Chronic wound healing problems
Femoral pseudoaneurysm or arteriovenous fistula.
Prevention Strategies:
Meticulous surgical technique, adequate heparinization, careful plaque dissection, and appropriate patch angioplasty can reduce restenosis
Aggressive medical management of risk factors and adherence to antiplatelet therapy are vital for long-term patency.
Prognosis
Factors Affecting Prognosis:
Severity of PAD, number of affected segments, runoff quality, presence of comorbidities, patient adherence to medical therapy and lifestyle modifications, and surgical technique
Successful endarterectomy generally offers good long-term limb salvage rates.
Outcomes:
Most patients experience significant relief from claudication and improvement in limb perfusion
Limb salvage rates are high when performed in appropriate candidates
Long-term patency rates for endarterectomy are generally good, though less durable than bypass in some series.
Follow Up:
Regular clinical follow-up is essential, including interval history, physical examination, and non-invasive vascular studies (e.g., duplex ultrasound) to monitor for restenosis or occlusion
Frequency of follow-up is typically every 6-12 months, or as clinically indicated.
Key Points
Exam Focus:
Indications for endarterectomy vs
bypass vs
endovascular intervention in CFA disease
Key steps of the procedure
Management of early and late complications
Importance of patch angioplasty
Role of antiplatelet therapy postoperatively.
Clinical Pearls:
Emphasize the importance of adequate exposure of the CFA, SFA, and PFA
Gentle dissection to avoid nerve injury
Thorough debridement of plaque
Secure closure to prevent bleeding
Consider a patch angioplasty to improve long-term patency
Assess runoff meticulously.
Common Mistakes:
Inadequate exposure of the arterial segments
Incomplete plaque removal
Injudicious use of clamps leading to ischemia
Poorly executed arteriotomy closure or patch angioplasty, leading to bleeding or pseudoaneurysm
Failure to manage underlying risk factors postoperatively.