Assessing the Perioperative Safety of Common Femoral Endarterectomy in the Endovascular Era

Abstract

Introduction:

Common femoral endarterectomy (CFE) has historically been the preferred treatment for atherosclerotic lesions involving the common femoral artery. The objectives of this study are to delineate the safety of this open procedure in the endovascular era, establish contemporary benchmarks for morbidity and mortality after CFE, and identify the subgroup of patients at increased risk of postoperative adverse events.

Methods:

Patients undergoing elective CFE in the 2007 to 2010 National Surgical Quality Improvement Project database were examined. Univariate analyses were used to identify the factors associated with major morbidity and mortality. Significant variables by univariate analysis were used to create multivariate logistic regression models for morbidity and mortality.

Results:

A total of 1513 patients underwent elective CFE. The 30-day mortality rate was 1.5%. Postoperative morbidities included cardiac (1.0%), pulmonary (1.9%), renal (0.4%), urinary tract infection (1.7%), thromboembolic (0.5%), neurologic (0.4%), sepsis (2.7%), superficial (6.3%), and deep surgical site complications (2.0%). At least 1 complication, including major and minor, was seen in 7.9% of the patients. By multivariate analysis, partial- and total-dependent functional status (odds ratio [OR] 9.0, 95% confidence interval [CI] 2.8-28.4 and OR 21.3, 95% CI 3.3-139.4) and dyspnea at rest (OR 8.2, 95% 1.2-58.8) predicted mortality. Independent predictors of morbidity include steroid use (OR 2.4, 95% 1.4-4.1), diabetes (OR 1.8, 95% CI 1.3-2.4), and obesity (OR 1.6, 95% CI 1.1-2.4).

Discussion:

Overall, CFE is tolerated well by the majority of patients with peripheral arterial disease. These results affirm the safety of CFE and can still be used as standard first-line therapy in most patients. Long-term results for endovascular interventions need to be studied to see whether high-risk patients that we identified for CFE would benefit more from an endovascular approach.

Keywords

peripheral vascular disease common femoral artery endarterectomy perioperative outcomes

Get full access to this article

View all access options for this article.

References

DeRubertis

Faries

McKinsey

. Shifting paradigms in the treatment of lower extremity vascular disease: a report of 1000 percutaneous interventions. Ann Surg. 2007;246(3):415–422.

Gallagher

Meltzer

Ravin

. Endovascular management as first therapy for chronic total occlusion of the lower extremity arteries: comparison of balloon angioplasty, stenting, and directional atherectomy. J Endovasc Ther. 2011;18(5):624–637.

Siracuse

Giles

Pomposelli

. Results for primary bypass versus primary angioplasty/stent for intermittent claudication due to superficial femoral artery occlusive disease. J Vasc Surg. 2012;55(4):1001–1007.

Bradbury

Adam

Bell

. Bypass versus angioplasty in severe ischaemia of the leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010;51(5 suppl):5S–17S.

Meltzer

Graham

Connolly

. Risk factors for early failure after peripheral endovascular intervention: application of a reliability engineering approach. Ann Vasc Surg. 2013;27(1):53–61. doi:10.1016/j.avsg.2012.05.002.

Sachs

Pomposelli

Hamdan

Wyers

Schermerhorn

. Trends in the national outcomes and costs for claudication and limb threatening ischemia: angioplasty vs bypass graft. J Vasc Surg. 2011;54(4):1021–1031.e1.

Ballotta

Gruppo

Mazzalai

Da Giau

. Common femoral artery endarterectomy for occlusive disease: an 8-year single-center prospective study. Surgery. 2010;147(2):268–274.

Malgor

Ricotta

JJ II

Bower

. Common femoral artery endarterectomy for lower-extremity ischemia: evaluating the need for additional distal limb revascularization. Ann Vasc Surg. 2012;26(7):946–956.

Kechagias

Ylönen

Biancari

. Long-term outcome after isolated endarterectomy of the femoral bifurcation. World J Surg. 2008;32(1):51–54.

10.

Kang

Patel

Conrad

Lamuraglia

Chung

Cambria

. Common femoral artery occlusive disease: contemporary results following surgical endarterectomy. J Vasc Surg. 2008;48(4):872–877.

11.

Andrews

Venbrux

Magee

Bova

. Placement of a flexible endovascular stent across the femoral joint: an in vivo study in the swine model. J Vasc Interv Radiol. 1999;10(9):1219–1228.

12.

Park

Won

Kim

Lee

. The arterial folding point during flexion of the hip joint. Cardiovasc Intervent Radiol. 2005;28(2):173–177.

13.

Silva

White

Quintana

Collins

Jenkins

Ramee

. Percutaneous revascularization of the common femoral artery for limb ischemia. Catheter Cardiovasc Interv. 2004;62(2):230–233.

14.

Paris

White

Collins

. Catheter-based therapy of common femoral artery atherosclerotic disease. Vasc Med. 2011;16(2):109–112.

15.

Bonvini

Rastan

Sixt

. Endovascular treatment of common femoral artery disease: medium-term outcomes of 360 consecutive procedures. J Am Coll Cardiol. 2011;58(8):792–798.

16.

Dattilo

Tsai

Rogers

Casserly

. Acute and medium-term outcomes of endovascular therapy of obstructive disease of diverse etiology of the common femoral artery. Catheter Cardiovasc Interv. 2013;81(6):1013–1022.

17.

American College of Surgeons-National Surgery Quality Improvement Program. ACS-NSQIP participant use file user’s guide. Accessed July 3 2013. https://acsnsqip.org/puf/docs/ACS_NSQIP_Participant_User_Data_File_User_Guide.pdf.

18.

Kwok

Lipsitz

Bader

Gawande

. Are targeted preoperative risk prediction tools more powerful? A test of models for emergency colon surgery in the very elderly. J Am Coll Surg. 2011;213(2):220–225.

19.

Cohen

Bilimoria

Hall

. Development of an American college of surgeons national surgery quality improvement program: morbidity and mortality risk calculator for colorectal surgery. J Am Coll Surg. 2009;208(6):1009–1016.

20.

Ramanan

Gupta

Fang

Forse

. Development and validation of a bariatric surgery mortality risk calculator. J Am Coll Surg. 2012;214(6):892–900.

21.

Giles

Hamdan

Pomposelli

Wyers

Siracuse

Schermerhorn

. Body mass index: surgical site infections and mortality after lower extremity bypass from the national surgical quality improvement program 2005-2007. Ann Vasc Surg. 2010;24(1):48–56.

22.

Meltzer

Graham

Connolly

. The comprehensive risk assessment for bypass (CRAB) facilitates efficient perioperative risk assessment for patients with critical limb ischemia. J Vasc Surg. 2013;57(5):1186–1195.

23.

Margenthaler

Longo

Virgo

. Risk factors for adverse outcomes following surgery for small bowel obstruction. Ann Surg. 2006;243(4):456–464.

24.

Subramanian

Saxena

Kang

Pollok

. Preoperative steroid use and risk of postoperative complications in patients with inflammatory bowel disease undergoing abdominal surgery. Am J Gastroenterol. 2008;103(9):2373–2781.

25.

Slaughter

Olson

Lee

Jr Ward

. A fifteen-year wound surveillance study after coronary artery bypass. Ann Thorac Surg. 1993;56(5):1063–1068.

26.

Arozullah

Khuri

Henderson

Daley

. Participants in the National veterans affairs surgical quality improvement program. development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med. 2001;135(10):847–857.

27.

Kubal

Srinivasan

Grayson

Fabri

Chalmers

. Effect of risk-adjusted diabetes on mortality and morbidity after coronary artery bypass surgery. Ann Thorac Surg. 2005;79(5):1570–1576.

28.

Siracuse

Nandivada

Giles

. Prosthetic graft infections involving the femoral artery. J Vasc Surg. 2013;57(3):700–705.

29.

Masoomi

Carmichael

Dolich

. Predictive factors of acute renal failure in colon and rectal surgery. Am Surg. 2012;78(10):1019–1023.

30.

Soga

Tomoi

Sato

Iida

Yokoi

. Clinical outcome after endovascular treatment for isolated common femoral and popliteal artery disease. Cardiovasc Interv Ther. 2013;28(3):250–257.