Isolated profundaplasty for limb salvage

Abstract

Fifty-four patients underwent 56 profundaplasties for limb salvage. All had stenosis > 50% in diameter of the deep femoral artery and associated superficial femoral artery occlusive disease. After profundaplasty, ischemic ulcers healed in 9 of 17 (53%) patients. Rest pain was relieved in 6 of 19 (32%) and areas of ischemic necrosis healed in 7 of 20 (35%). Cumulative patency of the deep femoral artery was 49% at 3 years but fell to 21% at 5 years, whereas cumulative limb salvage was 49% and 36%, respectively. Eleven of the required 28 amputations were performed in the immediate postoperative period. Profundaplasty was used to lower the amputation level and preserve the knee joint in six patients. The other five early amputations occurred in severely ischemic limbs without distal vessels suitable for bypass. The profundaplasty remained patent in all 19 patients who underwent below-knee amputation and 16 (84%) became ambulatory with a prosthesis. Hemodynamic data provided by determination of the profimdapopliteal collateral index predicted limb salvage in 10 of 11 (91%) of limbs when the index value was ~<0.19. Other clinical criteria, such as preoperative ankle-brachial index and the presence of diabetes mellitus, had no predictive value. Isolated profimdaplasty for limb salvage is an effective first procedure for selected patients and provides a reasonable alternative to primary amputation or high-risk distal bypass. When amputation is inevitable, effective perfusion of the proftmda femoris artery is essential for preservation of the knee joint and results in a high degree of functional rehabilitation.

Outcome After Endovascular Treatment of Deep Femoral Artery Stenosis:Results in a Consecutive Patient Series and Systematic Review of the Literature

“…Early complications of the endovascular approach seem superior to surgical morbidity and mortality. [6][7][8][9] Interpreting the published data on endovascular complications, one has to be aware that most of the results were ob-tained almost a decade ago; the more recent papers 15,19,21 reported no major complications and no profunda-specific catheter-associated problems. Therefore, particularly in elderly patients with multiple comorbidities and increased surgical risk, a percutaneous approach to profunda revascularization seems worth consideration.…”

“…6 After initial enthusiasm for this procedure, isolated profundaplasty was widely replaced by upcoming bypass surgical techniques, 7 although profundaplasty has the potential to relieve rest pain and facilitate ulcer healing in selected patients. 8,9 Particularly in patients with SFA occlusions and concomitant profunda stenosis who are not suitable for bypass surgery, surgical profundaplasty is considered the treatment of choice, but it is traditionally reserved for patients with critical limb ischemia (CLI).…”

Chapter IV: Treatment of Critical Limb Ischaemia

“…Besides its role for potential limb salvage profundoplasty can be of value in preserving the knee joint when amputation is deemed inevitable. 34 Studies on endovascular treatment of DFA obstructive disease have been mainly confined to relatively small case series, and long-term limb salvage rates are usually not reported. 38--43 Initial technical success rates of percutaneous DFA recanalisation range from 77% to 100%, 44 but long-term results seem less favourable.…”

The Current Role of Profundaplasty in Complex Arterial Reconstruction

“…For patients with femoral-popliteal occlusive disease, the presence of adequate collaterals from the profunda femoris to patent popliteal and/or tibial arteries is requi-site to achieve acceptable results with isolated profundaplasty. 11,111,19 Because the success of isolated profundaplasty is dependent on recruiting the maximum number of branch vessels that have been obstructed, the surgeon must be willing to undertake extended profundaplasty. The inadequacy of the procedure for patients with a gangrenous foot ulcer supports previous studies, which demonstrated that the success of profundaplasty in patients with ischemic tissue loss is poor.…”

“…This terminal branch of the common femoral artery is routinely employed by the vascular surgeon to provide outflow for aortofemoral bypass in the presence of superficial femoral artery occlusion.1-3 Direct modification of the profunda femoris (profundaplasty), by endarterectomy and/or patch angioplasty, as the principal means of revascularization for femoral-popliteal occlusive disease has been debated in the literature for many years and remains controversial.4-13 We have had a long-standing interest in the patient selection, techniques, and success of profundaplasty in lower extremity revascularization and have previously identified the value of profundaplasty for treating claudication and healing below-knee amputations during an era when the techniques were less sophisticated in performing distal arterial bypass for limb salvage. 11,12,[14][15][16] With the increasing success of distal arterial reconstruction using autogenous vein bypasses, the surgeon is less likely to rely on a reconstructed profunda femoris artery as the primary conduit to revascularize a limb with critical ischemia. This clinical review was undertaken to elucidate the role of profundaplasty in the current practice of lower extremity revascularization.…”