What is the treatment for bilateral occlusion of the femoral artery?

Treatment for Bilateral Femoral Artery Occlusion

For bilateral femoral artery occlusion, immediate revascularization is required, with the treatment approach determined by acuity: acute presentations demand urgent catheter-directed thrombolysis or surgical thrombectomy within hours, while chronic occlusions require staged or simultaneous bypass surgery using autogenous vein grafts, with endovascular options reserved for patients unfit for surgery. 1

Acute Bilateral Femoral Artery Occlusion

Immediate Assessment and Anticoagulation

• Assess limb viability immediately using the 5 P's: pain, paralysis, paresthesias, pulselessness, and pallor (plus "polar" for cold extremity) 1
• Initiate systemic anticoagulation immediately to prevent proximal and distal thrombus propagation, regardless of planned intervention 1
• Determine if the occlusion is embolic versus thrombotic, as this guides treatment selection 1

Revascularization Strategy for Acute Occlusion

For embolic occlusions:

• Surgical thrombectomy is the preferred approach for isolated suprainguinal emboli 1
• If embolic fragmentation with distal embolization has occurred, catheter-directed thrombolysis becomes the preferred option 1

For acute thrombotic occlusions:

• Catheter-directed thrombolysis is recommended for viable limbs when a guidewire can be passed across the lesion 1
• If guidewire passage fails, regional thrombolysis should be attempted 1
• One-year limb salvage rates with endovascular techniques are similar to surgery, with lower mortality but higher recurrent ischemia rates 1
• Mechanical thrombectomy techniques (suction embolectomy, rheolytic therapy) may allow more prompt flow restoration and are particularly useful when thrombolysis is contraindicated 1

Surgical intervention is reserved for:

• Failed thrombolysis or endovascular thrombectomy 1
• Situations where endovascular delay would jeopardize limb viability 1
• Irreversible limb ischemia requiring amputation 1

Critical Timing

• Revascularization must occur within 5 hours of symptom onset to prevent permanent neurological damage and limb loss 2
• Acute painless paraplegia can occur with bilateral femoral occlusion, representing a neurological emergency 2

Chronic Bilateral Femoral Artery Occlusion

Surgical Revascularization (Primary Approach)

For patients fit for surgery:

• Bilateral femoral artery bypass using autogenous saphenous vein is the gold standard, offering superior long-term patency 1
• Aorto-bifemoral bypass should be considered when there is concurrent aortoiliac disease, with mean 5-year patency of 85.8% and 10-year patency of 79.4% 1
• Autogenous vein is the conduit of choice for all femoral-popliteal bypasses, with significantly superior patency compared to prosthetic grafts 1
• Prosthetic conduits (PTFE or polyester) may be used for above-knee bypasses only when autogenous vein is unavailable, but expect lower patency rates 1

Surgical options for complex disease:

• Crossover femoro-femoro-popliteal sequential bypass is effective for combined iliac and superficial femoral artery disease, with 5-year limb salvage rates of 77% 3
• Hybrid procedures combining iliac stenting with femoral endarterectomy or bypass should be considered for ilio-femoral occlusive lesions 1
• Extra-anatomical bypass (axillofemoral-femoral) has poor patency (1-year: 62%, 5-year: 47%) and should only be used when no other revascularization options exist 1

Endovascular Approach (Alternative Strategy)

Endovascular therapy should be considered when:

• Patients have severe comorbidities making them unfit for surgery 1
• Short lesions (<25 cm) are present 1
• Life expectancy is limited (<2 years) 1

Technical considerations:

• Primary stent implantation is recommended over provisional stenting for iliac lesions 1
• Radial plus ipsilateral femoral approach is feasible for iliac CTO intervention, with similar success rates (98%) to bilateral femoral approach and potentially lower bleeding complications 4
• Drug-eluting balloons and stents may be considered for short lesions 1

Treatment Selection Algorithm

Step 1: Determine surgical candidacy

• Age, comorbidities, life expectancy >2 years, ability to tolerate anesthesia 1

Step 2: Assess vein availability

• Presence of adequate autogenous saphenous vein for bypass 1

Step 3: Define lesion characteristics

• Length of occlusion, presence of tandem lesions, extent of aortoiliac involvement 1

Step 4: Select approach

• Surgical bypass if: fit for surgery, vein available, life expectancy >2 years, long lesions 1
• Endovascular if: high surgical risk, short lesions, limited life expectancy 1
• Hybrid if: ilio-femoral disease with mixed lesion lengths 1

Critical Limb Ischemia Considerations

• Revascularization should be performed when possible to minimize tissue loss in patients with critical limb ischemia 1
• Interdisciplinary care team evaluation is mandatory before considering amputation 1
• Patients with diabetes require counseling on self-foot examination and healthy foot behaviors 1

Common Pitfalls

• Physical examination and vascular laboratory studies frequently fail to diagnose common femoral artery occlusion—angiography is definitive 5
• Do not perform revascularization solely to prevent progression to critical limb ischemia in asymptomatic patients 1
• Avoid prosthetic grafts for femoral-tibial bypass in claudication—unacceptable patency rates 1
• Bilateral femoral occlusion can present with painless paraplegia, mimicking neurological disease—maintain high suspicion 2