This was a retrospective study which included patients who underwent CFAE for the treatment of occlusive disease in the CFA, either alone or in combination with the treatment of other vessel segments. Between November 2001 and December 2007, a total of 46 patients, including 43 males and 3 females, who underwent CFAE were included. The patients were divided into 4 groups based on the extent of the disease and the operative procedures: 1) group I consisted of 11 patients who underwent CFAE alone; 2) group II of 15 patients who underwent CFAE with simultaneous IA endovascular treatment; 3) group III of 6 patients who underwent CFAE with simultaneous SFA endovascular treatment; and 4) group IV of 14 patients who underwent CFAE with simultaneous IA and SFA endovascular treatment or bypass surgery.
All patients had undergone preoperative peripheral vascular evaluation with physical examination and measurement of ankle-brachial index (ABI). The lesions were diagnosed with computed tomography angiography (CTA).
Baseline patient demographics and procedural details were recorded at the time of the procedure.
Demographic and preoperative characteristics of the patients are shown in Table 1. Age and comorbidities were similar between groups. The ABI value is shown to be highest for group I. This is because this group consisted of patients whose lesions were confined to the common femoral artery.
The degree of stenosis in the CFA was classified according to CTA images into 4 grades, as follows: minimal, 1%–49%; moderate, 50%–74%; high, 75%–99%; and occlusion, 100%.
There is no statistically significant difference in stenotic severity among the groups (P>0.05, Table 2).
Prior to operation, all patients were evaluated for clinical ischemic conditions according to the Rutherford classification. The distribution of patients in each group is shown in Table 3. In addition, the target lesions of the iliac and superficial femoral arteries were classified according to the TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Defining the incidence of group II by TASC in the iliac region, 4 cases fell into TASC B and 11 into TASC C. In the SFA region, 1 and 6 cases fell into TASC C and D, respectively. However, the SFA regions of group II patients could not be treated because the patients showed poor general condition. Even with the untreated SFA, we were able to achieve revascularization through the deep femoral artery, and succeeded in limb salvage. In the iliac region for group III, 2 and 4 cases were found to be healthy and TASC A cases, respectively. As the patients did not have hemodynamic problems, we did not treat them as target lesions. In the SFA region for group III, 2, 3, and 1 case were found to be TASC B, C, and D cases, respectively. In the iliac region for group IV, 1, 3, and 10 cases were found to be TASC B, C, and D cases, respectively. In the SFA region of group IV, 11 and 3 cases were found to belong to TASC B and D, respectively (Table 4).
2) Operative technique
CFAE was performed using the standard technique. Heparin sodium (100 U/kg) was administered intravenously during the procedure. The CFA was exposed, from the circumflex femoral branches down to the femoral bifurcation. The CFA was opened longitudinally toward the SFA or profunda femoris artery. The plaque was peeled away from the vessel wall in the direction of the arteriotomy, and removed (Fig. 1). Suture tackings of the plaque to the posterior part of the adventitia were placed at the distal end of the endarterectomy site to avoid plaque lifting, dissection, or thrombosis. The endarterectomized luminal surface was carefully inspected to check for a debris-free surface area. Patch angioplasty was then performed routinely using a bovine pericardium patch (Fig. 2). Concomitant ET for iliac or femoro-popliteal lesions was performed if necessary. ET was simultaneously performed in an operating room suite with a mobile C-arm. After CFAE, a 6F to 7F sheath was inserted over a guidewire through direct puncture on the patch. Lesions were crossed with a 0.035-inch angled or straight hydrophilic guidewire, with or without a supporting catheter. Lesions were treated with primary stenting for iliac occlusive disease, and balloon angioplasty and selective stenting for distal lesions. Completion angiography was performed and sutures were placed at the puncture site.
3) Medication and postoperative follow-up
Typically, aspirin (100 mg) and clopidogrel (300 mg), as well as cilostazol (200 mg), were orally administered as loading dose on the day of the surgery. After the procedure, all patients were treated with aspirin (100 mg/d), clopidogrel (75 mg/d), and cilostazol (200 mg/d) for 3 months, and all other drugs except clopidogrel were continued, as long as side effects did not occur.
ABI was performed to assess hemodynamic improvement. The patients were then followed-up every 1 to 2 months during the first 6 months, and every 3 months in the later period. During follow-up, patients with worsening clinical symptoms or a drop in ABI of more than 0.15 underwent CTA. Further procedures were performed at the discretion of the vascular surgeon.
4) Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics ver. 19.0 software (IBM Co., Armonk, NY, USA). Continuous data were compared using the Student’s t-test. Frequencies and categorical data were compared with the Fisher exact tests. The primary patency, assisted primary patency, and secondary patency were assessed by Kaplan-Meier analysis. A value of P<0.05 was considered statistically significant.