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

Article Outline

• Objective

• Methods

• Results

• Conclusion

• Copyright

Objective

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

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.

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)⁎

Insulin Regimen is an independent predictor for distal revasc. (OR=2.3 1.1-11; p=.02).

Increased Risk of Amputation for patients on dialysis (OR=5.9 1.4-25 p=.001).

⁎

p<.05.

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.

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN

Author Disclosures: R.D. Malgor, None; J.J. Ricotta, None; G.S. Oderich, None; M. Kalra, None; T.C. Bower, None; A.A. Duncan, None; P. Gloviczki, None.

PII: S0741-5214(09)00393-0

doi:10.1016/j.jvs.2009.02.135

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