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Superficial Femoral Artery Endarterectomy for Atherosclerotic Lower Extremity Occlusive Disease
The role for superficial femoral artery (SFA) endarterectomy, either localized or remote (semiclosed), has assumed a less prominent role in current vascular surgical practice. Though described previously, these techniques have been largely supplanted by the well-established superior results of vein bypass for treating SFA occlusive disease. The advent and popularization of a myriad of percutaneous endovascular therapies for treating SFA disease has further rendered this technique less common. Nevertheless, persistent clinical scenarios arise where SFA endarterectomy still has a useful and viable role and can serve as a good option among selected patients.
Open Endarterectomy
Historically, the open endarterectomy technique (Edwards procedure), comparable to a standard carotid endarterectomy technique, incorporates a longitudinal arteriotomy that traverses the length of the diseased arterial segment, through which a standard endarterectomy is performed under direct vision. The artery is subsequently closed with a patch angioplasty technique using saphenous vein, bovine pericardium, or an alternative patch material in order to preserve vessel lumen diameter.
Initially, this technique was applied even to diseased long segments (>25 cm). However, it has since fallen out of favor for several reasons. First, it was regarded as too time-consuming and tedious. Closure of a long arteriotomy required a long incision, and it required both potential sacrifice of long segments of vein (that could be otherwise used for a bypass). Lastly, this technique sometimes resulted in aneurysmal dilation of the patch, creating the potential for thromboembolic complications or the need for an additional surgical revision. Consequently, this technique was abandoned for long-segment occlusions of the SFA.
Short-segment focal SFA lesions, by contrast, may still be amenable to endarterectomy techniques, particularly among patients who have failed endovascular revascularization or who have poor conduit options for a conventional bypass. Inahara and Scott initially described their results using this technique among 100 patients (85% for claudication), emphasizing good patient selection (lesion length <15 cm), a deep endarterectomy plane, beveling and tacking points of transition between endarterectomized and untreated arterial segments, and patching 1 to 2 cm beyond both endpoints. As expected, the majority of these procedures were confined to the distal third of the SFA (75%). Patency rates at 5 and 10 years were 70% and 50%, respectively. Thirty endarterectomies failed, of which 14 required no additional treatment, and 16 required femoropopliteal bypass. Although these results are laudable, they preceded the era of endovascular therapies for treating SFA occlusive disease. Accordingly, short-segment endarterectomy is usually not employed as a first-line therapy.
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