SS4. Open Common Femoral Artery Endarterectomy for Lower Extremity Ischemia: Predicting the Need for Distal Limb Revascularization

Article Outline

• Objective
• Methods
• Results
• Conclusion
• Copyright

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Objective 

To evaluate the outcomes of open common femoral endarterectomy (OCFE) and define predictive factors for additional distal revascularization.

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Methods 

We reviewed 230 consecutive patients treated with OCFE (262 limbs) for lower extremity ischemia between 1997 and 2008. Patients were divided into two groups: OCFE alone (Group A, 169 limbs), or OCFE + distal revascularization (Group B, 93 limbs). Iliac disease in both groups was treated by endovascular approach. End-points were mortality, patency, re-intervention and limb salvage.

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Results 

Demographics, clinical severity scores, TASC II classification, and number of iliac interventions were similar in both groups, but Group B patients had more (p<.001) critical limb ischemia (Rutherford Category [RC] 5±1.4 vs 3±1.2) and diabetes (52% vs 33%). Technical success was obtained in all patients. In patients with RC 1-4 and RC 5 with TASC A-C lesions, clinical improvement (99% vs 100%) and limb salvage (99% and 100%) were similar for both groups, but Group B patients had higher re-intervention rates (14% vs 3%; p=0.01). For patients with more advanced disease (RC 5 with TASC D lesions or RC 6 regardless of TASC) distal revascularization (Group B) was associated with fewer (p<.001) re-interventions (24% vs 46%) and major amputations (5% vs 29%). Overall 1- and 5-year primary patency rates for OCFE were 97% and 94%, with 100% secondary patency at both time points. Overall survival was 93% at 1 year and 77% at 5 years. There was no difference in survival between the two groups for RC 1-5 (p=0.2), but for patients with RC 6, survival was improved in Group B (67% vs 39%; p=.09). Independent predictors for distal revascularization are listed in Table 1.

Table 1. Independent predictors for distal revascularization

	Odds ratio/95% CI amputation reintervention
Rutherford 5/TASC D	2.6(0.8-8.8)	5.9(2.1-16.8)⁎
Rutherford 6	8.6(2.44-30.6)⁎	8.9(2.1-37.3)⁎
Diabetes Mellitus¥	4.3(1.1-16)⁎	4.1(1.4-12.1)⁎
Chronic Renal Failure§	2.1(0.7-2.8)⁎	2.9(1.1-7.8)⁎
Anticoagulation (warfarin)	0.5(0.06-4.1)	5.3(1.7-16.1)⁎

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Conclusion 

OCFE alone is sufficient for patients who present with claudication or rest pain regardless of TASC lesion and with RC 5 and TASC lesions A-C. Distal revascularization should be considered in diabetics, and in patients with RC 5 and TASC D lesions and those with major tissue loss (RC 6) regardless of the extent of distal disease.