Annals of Vascular Surgery
Volume 21, Issue 1 , Pages 39-44, January 2007

Open Endarterectomy of the SPT Segment: An Experience

Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia

Perth, Australia

Article Outline

The purpose of the study was to evaluate the results of open endarterectomy in short atherosclerotic occlusions of the SPT segment (superficial femoral, popliteal, and tibioperoneal arteries). Retrospectively, records from July 1999 to June 2004 of patients who underwent open endarterectomy of lower limb arteries were verified; 63 patients with 66 lesions had open endarterectomy of the SPT segment as a primary procedure. At the time of this study, there were 57 patients alive and six dead, with the cause of death being unrelated to the procedure. The patients had a mean age of 71 ± 10.73 years, and there were 18 females and 45 males. All patients underwent routine follow-up at 1, 3, 6, and 12 months and yearly thereafter. Routine clinical examination and ultrasound were done to assess the outcome. The mean length of endarterectomized superficial femoral artery was 7.42 ± 3.66 cm (range 2-15). The lesions involved were the superficial femoral, popliteal, and tibioperoneal arteries (SPT segment). The primary cumulative patency rate by means of life-table analysis was 48.8% at 5 years (mean 12.7 months, range 1-60). During follow-up, percutaneous transluminal angioplasty was necessary in nine patients, for a primary assisted patency rate of 85.1% at 5 years. The location of recurrent stenoses after endarterectomy was usually at one of the ends of the endarterectomy site. Once a preferred technique, endarterectomy is now overshadowed by bypass procedures. Our clinical experience suggests that, in a select group of patients with SPT segment occlusions, open endarterectomy is technically feasible and should be used in cases with insufficient vein for bypass grafting. It also can be used as an alternative to allow the long saphenous vein to be reserved for a bypass procedure in the future.

 

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Introduction 

The ideal vascular procedure for occlusive arterial disease is a decision-making process between the type of lesion involved, patient factors, and the options available to deal with it. Endarterectomy as a surgical option for the management of occlusive disease of the femoropopliteal segment was introduced by Dos Santos1 in 1947 when he described endarterectomy of the atherosclerotic superficial femoral artery (SFA). Kunlin2 in 1949 reported his experience with femoropopliteal bypass using saphenous vein. Even though endarterectomy was one of the first described procedures, bypass has surpassed it as the preferred procedure for occlusive disease in the infrainguinal region. The authors believe that the decline in the frequency of infrainguinal endarterectomy occurred as a result of several series reporting an inferior long-term patency rate with endarterectomy.3, 4 Unfortunately, the indications for operation in these reports were obscure, and many patients underwent long endarterectomies for diffuse superficial femoral disease. Clinical experience suggested that endarterectomy may be a durable procedure if applied to patients with localized superficial disease. In the context of these considerations, we reviewed a 5-year experience with endarterectomy of the superficial femoral, popliteal, and tibioperoneal arteries—the “SPT segment (Fig. 1)—which excluded the common femoral artery and the profunda orifice due to well-documented literature on the success of endarterectomy in this region.5 In this study of patients who underwent open endarterectomy, primary and secondary patency, complications, as well as secondary procedures were evaluated.

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Materials and Methods 

Endarterectomy of localized lesions of the SPT segment was performed in 63 patients between July 1999 and June 2004. All endarteriectomies were performed as a primary procedure and not as adjunct at the bypass site, and all lesions were <15 cm in length. There were 45 men and 18 women, with a median age of 71 ± 10.6 years. Hypertension was present in 37% of patients, hypercholesterolemia in 28% of patients, symptomatic coronary artery disease in 22% of patients, diabetes mellitus in 13% of patients, and a significant past history of chronic obstructive pulmonary disease (especially in smokers) and cerebrovascular accident in 4.5% (n = 3) of patients. About 57% of the patients had a history of current or significant past smoking.

The indication for operation was disabling intermittent claudication alone in 42 (64%) patients and with rest pain in two (3%) patients. Ischemic ulceration and/or gangrene alone was present in 12 (18%). In 10 (15%) patients, there was a combination of all the above three symptoms (Fig. 2).

Most patients underwent duplex ultrasound and ankle brachial pressures before angiography while being assessed in the clinic for short-distance claudication and rest pain, while patients with ischemic ulceration and gangrene underwent angiogram after clinical assessment for suitability to undergo an operative procedure. Preoperative arteriography in all patients was reviewed, and the lesions treated were documented with regard to site and length and classified per the Trans-Atlantic Inter-Society Consensus (TASC) document. The exact length of the endarterectomized segment was obtained from the operative report and angiogram in all patients. The length ranged 2-15 cm, with a mean of 7.42 ± 3.66 cm.

A single open technique was used to accomplish the endarterectomy. The proximal and distal lengths of the occluded segment were marked on the skin prior to surgery with the use of ultrasound to reduce the length of the incision used for the procedure. Most of the lesions in the study were approached with medial exposure of the artery except for isolated popliteal segments that were approached after posterior exposure of the artery with the patient in the prone position. After adequate heparinization and proximal and distal segment control of the involved segment of the artery, a single longitudinal arteriotomy was made and extended into the proximal and distal patent segment to facilitate endarterectomy and avoid accidental extension of the endarterectomy into the patent segment. The proximal and distal ends of the plaque are divided with Potts scissors, and the distal end was tacked down using a 7-0 polypropylene suture to avoid dissection, with restoration of the flow. The endarterectomized surface was cleared of residual circular medial fibers, removing them with a fine forceps and heparinized saline irrigation. All arteriotomies were closed with a patch using a 6-0 polypropylene suture.

Vein patch closure was done in 73% of cases, and of these, 28 were forearm vein, preferably basilic; short saphenous was used in 12 cases as an easy access to the vein, when the patient was prone for popliteal artery endarterectomy. An operative-site long saphenous vein was used in five cases when the vein was assessed to be <3 mm in diameter, making it unsuitable for bypass. Dacron® (DuPont, Wilmington, DE) patch was used in 26% of cases where a suitable vein was difficult to find. In six cases, as an additional procedure, an artery distal/proximal to the endarterectomy site was angioplastied to improve the inflow or outflow. A drain was always inserted, and antibiotics were given at the start of the operation. Intraoperative angiography was used if there was any doubt about the proximal or distal flow on release of the clamps.

Patency of the reconstructed vessel was assessed with duplex scan, ankle-brachial index, or palpation of the pedal pulses when present. Survival curves were used in the analysis of the data for patency.

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Results 

Arterial continuity and flow were restored in 66 limbs. All patients were discharged with patent reconstructions. The mean follow-up was 6 months. Analysis of long-term results was based on the number of limbs, and the standard life-table method was used to determine late patency rates. The cumulative patency rates were 63.57% at 1 year and 48.88% at 5 years.

There was no difference between the limb side affected (left, n = 35; right, n = 31 patients). The length of the lesion varied from 2 to 10 cm, and in two cases, due to operative findings, the endarterectomy was extended to about 15 cm, hence making the average 7.42 ± 3.66 cm. The segments involved were the SFA alone in 34 cases, with a mean and standard deviation (SD) of 7.14 ± 3.4 cm in length; the SFA with the popliteal in seven cases, with a mean and SD of 11.42 ± 2.6 cm in length; the popliteal artery alone in 19 cases, with a mean and SD of 5.68 ± 2.8 cm in length; the popliteal with tibioperoneal involvement in three cases, with a mean and SD of 11.6 ± 1.5 cm in length; and the tibioperoneal segment alone in three cases, with a mean and SD of 5.3 ± 4 cm in length (Fig. 3). The lesions treated were TASC B (45.4%) and C (45.4%) of the femoropopliteal segment and D (9.09%) of the infrapopliteal segment (Fig. 4).

During the follow-up period, patients' claudication symptoms were evaluated at intervals of 1, 3, 6, and 12 months and yearly thereafter for 5 years; and repeat arterial duplex scans were done, if symptoms recurred, pulse diminished, or the ankle-brachial index decreased. Angiography was performed to confirm any significant abnormality detected on follow-up.

Two endarterectomies failed at 30-day follow-up, of which one patient had a below-knee amputation following spreading cellulitis and another had femoropopliteal bypass done. In two cases where synthetic patch was used, serial duplex ultrasound revealed critical stenosis at the distal end of the endarterectomy site at 3 and 6 months each, suggesting intimal hyperplasia. Percutaneous transluminal balloon angioplasty was done in both, and they remained patent for the rest of the follow-up period. Four patients had occlusion of the endarterectomy site at 3 months (n = 1), 6 months (n = 1) and 1 year (n = 2) but remained asymptomatic with healed ulcers and were managed conservatively.

Perioperative morbidity occurred in five (10.6%) patients. Superficial wound infections developed in three patients, and all healed without sequelae with antibiotic therapy. Wound hematomas developed in the immediate postoperative period in two patients, and in one the skin at the incision site showed early necrotic edges due to tense hematoma; in one case where a synthetic patch was used, wound exploration revealed endarterectomy patch suture site bleeding requiring resuturing of the edge and evacuation of hematoma. In the other, there was a longitudinal tear in the vein patch due to infection and the artery and surrounding tissue were inflamed and so friable that the artery had to be tied off and the patient had to be rebooked at a later date for a femoropopliteal bypass once the infection had settled. There were six deaths during the follow-up period, which were not related to surgery, and patency of the endarterectomy site was documented during the last follow-up visit in all six cases. The overall survival rate was 95.2%.

Failure of the reconstruction occurred during the early (less than 30-day) postoperative period in two patients, for a perioperative patency rate of 96.9%. These failures could be related to technical problems at the time of operation in one as the endarterectomy was performed in the distal popliteal artery at the trifurcation with poor infrapopliteal flow on preoperative angiogram. Among the two patients with hemodynamic failure, one required a below-knee amputation and the other underwent a femoropopliteal reversed vein bypass.

The long-term patency of the reconstructions is illustrated by the life-table analysis. The cumulative primary patency rates were 64%, 54%, and 49% at 1, 2, and 3 years, respectively, with an assisted primary patency of 85% at 3 years (Fig. 5).

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Discussion 

On August 27, 1946, femoral artery endarterectomy, or “arterial disobliteration” as it was initially called, was performed by Dos Santos1 under local anesthesia. The method Dos Santos described in his writings as “whole of the central block was grasped and twisted until it came out like a tooth, followed by a strong jet of blood” was the first attempt to reestablish circulation in arteries affected by chronic occlusions by removing the obstructing process and restoring permeability.6

In the early 1960s, several reports described modifications of the technique, which included patch closure of the endarterectomized segment7 and the use of a distal transverse arteriotomy to prevent subintimal dissection at the terminating point of the endarterectomy.8

As other reconstructive techniques were developed to treat atherosclerotic occlusive vascular disease, endarterectomy and bypass grafting emerged as the preferred techniques to revascularize ischemic vascular beds.

The results of endarterectomy and vein bypass for superficial femoral occlusive disease have been compared in the literature in the two decades following the 1960s.3, 4, 9, 10 None of the studies was randomized, and the results were in favor of bypass. In addition, in the studies in which the techniques were explicitly described, it is apparent that many patients who underwent long endarterectomies for diffuse disease of the SFA were included in the data analysis.3 The reports of Inahara and Scott5 and Kenneth et al.11 are the only two recent series of patients undergoing superficial femoral endarterectomy. Inahara and Scott5 showed that 85% of endarteriectomies were done for claudication, 92% were <15 cm in length, and 74% were localized to the area of the adductor canal. With a single longitudinal arteriotomy with vein patch closure in most patients, these investigators were able to have a 5-year cumulative patency rate of 70%. Kenneth et al.11 substantiated the results of Inahara and Scott, with two-thirds of their reconstructions remaining patent 3 years after operation.

Through the years different techniques of endarterectomy have been described in the literature, which can be classified into three main procedures: open, semiclosed, and remote. In the open method, through a longitudinal arteriotomy, the whole of the atheromatous segment is exposed and an endarterectomy performed; the arteriotomy is generally closed with a patch (vein or synthetic). In the semiclosed method, the upper and lower limits of atheroma are exposed, usually through two separate incisions, and the endarterectomy is completed by passing a stripping loop or ring down the artery in the plane of the endarterectomy.12 The lower atheromatous flap is secured with sutures. In remote endarterectomy, the atheromatous core is stripped from above in a manner similar to the semiclosed operation. At the distal end of the core, a ring cutter cuts through the atheroma and the distal flap is secured by an intraluminal stent. This technique uses a single groin incision, unlike the semiclosed technique.13, 14

Even though bypass procedures have been advocated for femoropopliteal occlusive disease, endovascular procedures are slowly replacing them. Subintimal angioplasty awaits uniform acceptance due to success rates in only a few centers.15 The 5-year patency following percutaneous transluminal angioplasty for long occlusive lesions is ∼30%,16 whereas the 5-year patency rates for above-knee veins and synthetic bypass are 60-75%17, 18 and 40%,19 respectively. The equivalent results following vein and synthetic bypass below the knee are 61%20 and 12%.21 Mortality following femoropopliteal bypass is 3%.19 Morbidity with wound infection is common, being 13% and 11% following femoropopliteal bypass using vein and synthetic graft, respectively.22 Wound infections can cause high risk for graft infections that have high mortality and high rates of amputation in survivors.

Technical factors appeared to be extremely important in obtaining a satisfactory operative result. The most significant problem in performing this procedure was in infrapopliteal disease, where good exposure was necessary to avoid subintimal dissection as distal transverse arteriotomy was difficult. Tacking of the distal intimal was essential in preventing dissection on restoring flow. As ultrasound guidance was used for preoperative marking of the lesion on the skin, technical success was 100%. Unlike in other methods of endarterectomy (semiclosed and remote), where lesions with heavily calcified intima core, difficult end point plaques, and vessel perforation due to difficult instrumentation limit their use and decrease technical success, leading to abandonment of the procedure,23, 24 open endarterectomy can be safely performed under direct vision.

A renewed interest in endarterectomy has been evoked with the recently published semiclosed and remote endarterectomy studies by Rosenthal et al.23 and Smeets et al.24 Although the number of patients in our study would reduce the statistical significance, the primary patency (49%) and assisted primary patency (85%) rates at 3 years are comparable with those of Rosenthal et al.23 (primary 68.6% and assisted primary 88.5% at 18 months) and Smeets et al.24 (primary 37.8% and assisted primary 47.9% at 5 years).

The present study illustrates that endarterectomy of the SPT segment should be considered a viable alternative to bypass techniques in selected patients with localized disease. Endarterectomy provides for revascularization without use of the long saphenous vein. In addition, the greater saphenous vein is spared for use if a subsequent reconstruction becomes necessary. We did not compare the results between endarterectomy and vein bypass. In addition, amputation may be avoided in the vast majority of patients presenting with threatened limbs. Femoropopliteal/distal bypass may be undertaken if the endarterectomized segment occludes, and in these patients endarterectomy will have provided for a substantial delay in the development of an unreconstructable situation.

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References 

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 Presented at the 6th International Congress of Asian Vascular Society, Bangalore, India, November 4-7, 2004.

PII: S0890-5096(06)00026-4

doi:10.1016/j.avsg.2006.06.002

Annals of Vascular Surgery
Volume 21, Issue 1 , Pages 39-44, January 2007

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