Effect of adjunct femoral endarterectomy in lower extremity bypass on perioperative and 1-year outcomes

Abstract

Introduction Isolated common femoral endarterectomy was recently reported to have a thirty-day mortality of 3.4%. The impact of adjunctive femoral endarterectomy at the time of lower extremity bypass is not well described and therefore the purpose of this study is to determine its associated perioperative and long-term risk. Methods Patients undergoing initial lower extremity bypass in the VSGNE from 2003–2015 were identified. After univariate analysis, multivariable logistic regression was used to identify the independent association of endarterectomy with adverse perioperative events. Kaplan-Meier and Cox hazard models were utilized for 1-year analysis. Results After exclusions 4496 patients were identified as undergoing infrainguinal bypass (33% with endarterectomy). There was no difference in proportion with chronic limb-threatening ischemia (CLI)(68% vs. 67%, P=.24), or tissue loss (of those with CLI: 65% vs. 63%, P=.34), between the adjunctive endarterectomy group and bypass alone, respectively. Patients undergoing adjunctive endarterectomy were older (mean 68yr vs. 67yr, P=.02), more likely white (95% vs. 93%, P=.02), smokers (91% vs. 87%, P=.001), and more often had prior CABG/PCI (34% vs. 31%, P=.02). The endarterectomy cohort had similar 30-day mortality (CLI: 2.6% vs. 2.9%, P=.60; Claudication: 0.2% vs. 0.4%, P=1.0) despite longer operative time (median 268min vs. 210min, P<.001) and increased blood loss (median 250cc vs. 180cc, P<.001). Patients with CLI undergoing adjunctive endarterectomy had more in-hospital MIs (6.2% vs. 3.8%, P=.003) and transfusions (11% vs. 6.8%, P<.001). At one-year this group had a suggestion of improved freedom from major amputation (91% vs. 87%, P=.049) and AFS (80% vs. 76%, P=.03) that did not reach significance after adjustment. For patients with claudication and adjunctive endarterectomy rates of MI (2.4% vs. 0.9%, P=.02), renal dysfunction (3.6% vs.1.4%, P=.01), SSI (5.0% vs. 2.6%, P=.02), and transfusion (4.6% vs. 1.8%, P=.002) were higher. After adjustment, all patients undergoing adjunctive endarterectomy were at increased risk of MI (OR 1.6, 95%CI 1.1–2.2), SSI (1.5, 1.1–2.0), and bleeding requiring transfusion (1.8, 1.4–2.3). There were no differences in one-year survival for either CLI or claudication groups and no difference in all one-year endpoints, for patients with claudication. Conclusion Adjunctive femoral endarterectomy with bypass is safe, with no difference in perioperative or 1-year mortality compared to bypass. However, surgeons should be aware that adjunctive endarterectomy is associated with increased risk of bleeding, surgical site infection, and myocardial infarction, likely from these patients’ disease burden and presumed more extensive atherosclerosis.

Predictors for Distal Revascularization Following Femoral Endarterectomy in Chronic Limb-Threatening Ischemia Patients

“…The 1-year mortality rate of 14.8% was statistically similar among the 3 groups. Although this rate was comparable to what was reported in the literature, 24,25 it was double the mortality rate reported by Malgor et al 4 This difference may due to the higher prevalence of CHF, CKD, DM, and limited mobility in our cohort, all of which were known risk factors for mortality in CLTI patients undergoing CBI. 26 Based on our results, FEA alone was a sufficient choice for CFA disease RC 2-3 and FP TASC II A-C as these such groups did not significantly increase the re-intervention rates (Table 4).…”

Infrainguinal open reconstruction: a review of surgical considerations and expected outcomes

“…Overall, 1-year postoperative freedom from major amputation and amputation-free survival has been reported as 87% and 76%, respectively. 63 Despite patent bypass grafts, some patients do not achieve limb salvage, and studies have demonstrated similar 1-year amputation rates in patients with patent (6.3%) and occluded (5.7%) grafts. 64 Thus, identification of patient comorbidities contributing to amputation in patent grafts in addition to prevention of graft failure is essential in limiting limb loss.…”

Using Isolated Femoral Bifurcation Endarterectomy or Combined with Bypass Surgery for Patients with Chronic Limb-Threatening Ischemia

“…They demonstrated that patients who underwent an additional FBE with bypass had improved 1-year freedom from major amputation compared with those who underwent bypass only (91% vs. 87%). Their results confirmed that additional FBE improves limb perfusion through the DFA and its collaterals, which is cause for a better outcome [9].…”

“…The gold standard for the treatment of patients with CLTI due to lesions of the common femoral artery (CFA) and its bifurcation is femoral bifurcation endarterectomy (FBE) [3][4][5][6][7][8]. In cases of CFA lesions combined with long superficial femoral artery (SFA) lesions, data regarding the best treatment are scarce [9]. Some authors preferred primary isolated FBE [10], whereas others advocated FBE combined with bypass surgery [9].…”

“…In cases of CFA lesions combined with long superficial femoral artery (SFA) lesions, data regarding the best treatment are scarce [9]. Some authors preferred primary isolated FBE [10], whereas others advocated FBE combined with bypass surgery [9]. Now, the current guidelines recommend in-line flow via a targeted arterial pathway for optimal treatment of CLTI [2].…”