What is the best management approach for a patient with an occluded right common femoral artery and mild-to-moderate rest ischemia bilaterally?

Management of Occluded Right Common Femoral Artery with Mild-to-Moderate Rest Ischemia

This patient requires urgent revascularization through a hybrid approach combining surgical endarterectomy or patch angioplasty of the occluded right common femoral artery with assessment and potential optimization of the existing femoral-femoral bypass graft, as common femoral artery occlusions cannot be adequately treated with endovascular therapy alone and rest ischemia indicates chronic limb-threatening ischemia requiring prompt intervention. 1

Clinical Classification and Urgency

• The presence of rest ischemia bilaterally classifies this patient as having chronic limb-threatening ischemia (CLTI), which carries a 30-day mortality risk up to 22% if major amputation becomes necessary 1
• Rest ischemia with ABI typically <0.4 places tissue viability in jeopardy and requires rapid restoration of inline blood flow to the foot 1
• This is a subacute limb-salvage situation rather than acute limb ischemia, allowing for planned staged intervention rather than emergency surgery 1

Multidisciplinary Team Management

A vascular team including at minimum a vascular physician, vascular surgeon, and interventional radiologist must be assembled immediately (Class I recommendation). 1

• This team-based approach is mandatory for all CLTI patients to optimize limb salvage outcomes 1
• The team should evaluate both the patent femoral-femoral bypass graft and the occluded native right common femoral artery to determine optimal revascularization strategy 1

Revascularization Strategy

Addressing the Common Femoral Artery Occlusion

Surgical intervention is required for the occluded right common femoral artery, as this anatomic location mandates open surgical repair rather than endovascular therapy. 1, 2

• Common femoral artery occlusions require endarterectomy, patch angioplasty, or graft replacement with profundaplasty 2
• Hybrid revascularization combining surgical treatment of the common femoral artery with endovascular therapy for any associated inflow or outflow disease is the preferred approach 1
• The 2024 ESC guidelines specifically state that hybrid procedures should be performed in a one-step modality when common femoral artery occlusion requires endarterectomy in addition to other disease 1

Evaluating Inflow Disease

For combined inflow and outflow disease with CLTI, inflow lesions must be addressed first (Class I recommendation). 1

• The patent left-to-right femoral-femoral bypass graft should be assessed for adequacy of inflow from the left iliac system 1
• If hemodynamically significant inflow disease is uncertain, intra-arterial pressure measurements across suprainguinal lesions should be obtained before and after vasodilator administration 1
• Biphasic flow bilaterally suggests adequate inflow currently, but pressure gradients should be confirmed 1

Addressing Persistent Ischemia

If symptoms of CLTI persist after inflow revascularization, an outflow revascularization procedure must be performed (Class I recommendation). 1

• Pulsatile flow to the foot is generally necessary for treatment of rest ischemia, requiring ABI >0.8 after inflow correction 1
• The absence of focal stenosis on current imaging suggests the rest ischemia may be related to inadequate collateralization around the occluded right common femoral artery rather than discrete outflow lesions 1

Optimal Medical Therapy

All patients with CLTI must receive guideline-directed medical therapy regardless of revascularization plans. 1

• Antiplatelet therapy: Aspirin 75-325 mg daily is mandatory to reduce major adverse cardiac events 1
• Statin therapy: High-intensity statin regardless of lipid levels to reduce cardiovascular mortality 1
• Antihypertensive therapy: If hypertensive, to reduce stroke, MI, heart failure, and cardiovascular death 1
• Infection control: If any ulceration or tissue breakdown is present, antibiotics must be initiated (Class I recommendation) 1

Post-Revascularization Management

• Dual antiplatelet therapy may be reasonable following revascularization to reduce limb-related events 1
• Lower-extremity exercise training is contraindicated until any wounds are healed (Class III recommendation) 1
• If ulcers are present, aggressive offloading of mechanical tissue stress is mandatory to allow wound healing (Class I recommendation) 1

Critical Pitfalls to Avoid

Do not attempt endovascular therapy alone for common femoral artery occlusions - this anatomic location requires surgical exposure for adequate treatment, and attempting endovascular therapy will fail and delay definitive management 1, 2

Do not assume the femoral-femoral bypass graft is functioning adequately without pressure measurements - even with biphasic flow, hemodynamically significant stenosis may be present requiring correction before addressing outflow 1

Do not delay revascularization in the presence of rest ischemia - this represents CLTI with tissue viability at risk, and conservative management alone will lead to tissue loss and potential major amputation 1