Is femoral endarterectomy a high-risk procedure?

Femoral Endarterectomy: Risk Assessment

Common femoral endarterectomy (CFE) is not a benign procedure and carries significant risk for perioperative morbidity and mortality, particularly in patients with multiple comorbidities or critical limb ischemia. 1

Procedure-Related Risks

Morbidity

• CFE is associated with potential for short-term morbidity, with minor or major complications occurring in 7.9% of patients according to National Surgical Quality Improvement Project data 2
• Local complications include:
  • Wound infection (3.4%)
  • Lymphatic fistula (3.4%)
  • Need for procedure-related local revision (8.6%) 2
• In a contemporary cohort study, 17% of patients sustained local complications following CFE, with obesity being a significant risk factor 1
• Serious systemic complications occurred in 15% of patients, associated with chronic limb-threatening ischemia and high American Society of Anesthesiologists (ASA) class 1

Mortality

• Six-month mortality rate following CFE can reach 13%, with high ASA class being independently predictive of mortality 1
• Mortality risk is significantly higher in patients with critical limb ischemia (CLI) compared to those with claudication 3
• The 30-day mortality rate is approximately 3.4%, with 30% of deaths occurring after hospital discharge 4

Risk Stratification

Higher Risk Patients

• Patients with chronic limb-threatening ischemia 1
• High ASA class (independently predictive of mortality) 1
• Elderly patients 4
• Patients on dialysis 1
• Non-independent functional status 4
• Emergency procedures 4

Procedure Durability vs. Risk

• Despite the risks, CFE demonstrates excellent long-term patency:
  • Primary patency rates of 78.5% at 7 years 2
  • 5-year primary patency rates of 100% for claudication and 95% for CLI 3
• The procedure's durability must be weighed against its perioperative risks when selecting appropriate candidates 2, 1

Comparison with Alternative Approaches

• Meta-analytic data comparing CFE with endovascular interventions show:
  • Similar risk of 30-day mortality and early reintervention
  • Less procedural morbidity with endovascular approaches
  • Similar 1-year primary patency
  • Similar need for late reintervention 2
• Endovascular approaches may be preferred in patients with:
  • History of radiation therapy to the area
  • Previous surgery to the local area
  • Severe obesity 2

Clinical Decision Making

• Selection of revascularization approach should be based on:
  • Patient's goals
  • Anatomic findings
  • Perioperative risk assessment
  • Anticipated benefit 2
• CFE should be reserved for:
  • Patients who failed nonsurgical therapy
  • Favorable arterial anatomy for durable results
  • Acceptable risk of perioperative adverse events 2
• In cases where endovascular approaches may adversely affect profunda femoris artery pathways, open surgical endarterectomy is preferred 2

Post-Procedure Considerations

• Close postoperative follow-up is essential as >60% of combined mortality/morbidity events occur after discharge 4
• Wound complications are particularly common (8%), with 86% occurring after hospital discharge 4

In summary, femoral endarterectomy carries significant perioperative risks that must be carefully considered when selecting patients for this procedure, particularly in elderly individuals and those with multiple comorbidities or critical limb ischemia.