What is the surgical treatment for an occluded common femoral artery?

Surgical Treatment for Occluded Common Femoral Artery

Common femoral artery endarterectomy (CFE) is the definitive surgical treatment for occluded common femoral artery and should remain the standard of care, achieving 91-100% primary patency at 5 years with minimal perioperative mortality (0-2.3%). 1, 2, 3

Primary Surgical Approach

Endarterectomy is the gold standard procedure for CFA occlusive disease, whether isolated or combined with profundoplasty or short-segment (<1 cm) superficial/deep femoral artery endarterectomy. 2 This approach delivers:

• Technical success rates of 98-100% across multiple studies 1, 4, 2
• 5-year primary patency of 91-100% for isolated CFE 1, 2, 3
• Assisted primary patency of 100% at 5 years 1, 2, 3
• Perioperative mortality of 0-2.3%, substantially lower than major amputation (4-30%) 1, 2, 5

Hybrid Procedures: When to Combine CFE with Endovascular Therapy

When CFA occlusion coexists with iliac disease, hybrid revascularization combining CFE with iliac stenting should be performed in a one-step procedure. 6

Specific Indications for Hybrid Approach:

• Simultaneous iliac artery occlusive disease requiring inflow treatment (present in 40-68% of cases) 1, 5
• Combined CIA and EIA lesions (61% of hybrid cases) or complete CIA/EIA occlusions (41% of cases) 5
• Concomitant superficial femoral artery disease requiring outflow treatment 1

Hybrid Procedure Outcomes:

• 5-year primary patency of 60% for combined CFE with iliac stenting (bare metal) 5
• 5-year primary patency of 87% when stent grafts are used instead of bare metal stents 5
• Primary-assisted patency of 97-100% at 5 years 5
• Clinical improvement in 92-100% of patients 1, 5

Critical technical point: When using covered stents for iliac disease during hybrid procedures, 5-year primary patency increases from 53% (bare metal) to 87% (stent grafts). 5

Surgical Technique Considerations

Patch Closure vs Primary Closure:

• Both techniques achieve excellent patency, though some data suggest patch closure may reduce reintervention rates (12.8% vs 26.9%, though not statistically significant) 4
• Patch options include: autogenous vein (preferred), Dacron, or biological patches 4

Operative Details:

• Regional anesthesia is standard 2
• Mean operative time: 1.3 hours for isolated CFE 2
• Average hospital stay: 2-3 days 1, 5

When to Address Inflow vs Outflow Disease

For patients with combined inflow (iliac) and outflow (femoral-popliteal) disease with critical limb ischemia, address inflow lesions first. 6, 7

• If CLI symptoms or infection persist after inflow revascularization, perform outflow revascularization as a second procedure. 7
• For claudication with isolated CFA disease and adequate collateralization, CFE alone is sufficient. 2

Perioperative Complications and Management

Major Complications (5% incidence):

• Early graft failure (typically from untreated inflow lesions) 1
• Hematoma requiring reintervention 1
• Wound infection requiring surgical intervention 1

Minor Complications (6.6-9% incidence):

• Superficial wound infections (most common, managed conservatively) 1, 2
• Lymph leak (managed conservatively) 1

Critical caveat: Congestive heart failure is the only independent predictor of primary failure (OR 18.5) and need for reintervention (OR 5.3). 1

Long-Term Outcomes and Surveillance

Patency Rates:

• 1-year primary patency: 90-100% 1, 4, 3
• 5-year primary patency: 91-100% 1, 2, 3
• Limb salvage at 5 years: 82-100% 4, 3

Survival:

• 5-year survival: 70-89% for claudication patients 1, 3
• 5-year survival: 33% for CLI patients (reflecting underlying comorbidities) 3

Reintervention:

• Freedom from reintervention at 5 years: 78-79% 1, 2
• When reintervention needed: 14% require endovascular procedures, 10% require surgical inflow procedures 5

Alternative Surgical Options for High-Risk Patients

For patients with extensive aortoiliac disease who are not candidates for aortobifemoral bypass due to severe comorbidities, axillofemoral-femoral bypass is indicated (Class I, Level of Evidence B). 7, 8

• Operative mortality for axillofemoral bypass: 4.9-6% (higher than CFE but acceptable for high-risk patients) 7
• This applies to patients with severe COPD, poor cardiac function, or hostile abdomen 8

Common Pitfalls to Avoid

1. Failing to assess and treat concomitant iliac disease: Untreated inflow lesions are a primary cause of early CFE failure 1
2. Performing CFE alone in CLI patients with inadequate collateralization or poor runoff: These patients require assessment of the entire arterial tree 2
3. Using bare metal stents instead of covered stents in hybrid procedures: This reduces 5-year patency from 87% to 53% 5
4. Inadequate preoperative cardiac risk stratification: MI occurs in 0.8-5.2% of cases and is a leading cause of perioperative mortality 7