title: Management of flush superficial femoral artery occlusions with combined open femoral endarterectomy and endovascular femoral-popliteal angioplasty and stent-grafting.
abstract: BACKGROUND
  Flush occlusions of the superficial femoral artery (SFA) often preclude endovascular interventions for femoral-popliteal lesions. Furthermore, some investigators have found poor results with angioplasty and stenting or stent-grafting of such lesions. For suitable patients with TransAtlantic Inter-Society Consensus (TASC) C and D femoral-popliteal lesions involving a flush occlusion of the SFA, we have adopted a technique to manage this disease pattern by combining femoral endarterectomy through a single, small groin incision with distal superficial femoral-popliteal stent-grafting. In this article we have described our technique and results in 14 consecutive patients.
  
  
  METHODS
  A total of 14 patients who underwent this hybrid procedure between May 2005 and April 2009 were identified from our prospectively gathered registry. Data on indications, complications, length of hospital stay, pre- and postoperative ankle-brachial indices, patency determined by duplex ultrasonography, limb salvage rates, and functional results were collected.
  
  
  RESULTS
  Of the 14 patients, nine were operated on for disabling claudication, two for rest pain, and three for tissue loss; three fit TASC C criteria and the remaining 11 fit TASC D. In all, 12 patients had stent-grafts placed and two had bare-metal stents inserted. The median ankle-brachial index of the affected leg was 0.61 (range, 0.23-1.71) before surgery and 0.99 (range, 0.63-1.39) after surgery (p = 0.034). There were no significant complications associated with the procedure. One patient died secondary to unrelated causes 5 months later, two did not return for follow-up after discharge, and three were lost to follow-up after primary patency was confirmed at 2, 4, and 4 months, respectively. Of the remaining eight patients, four still have primary patency of their stent-grafts at 52, 19, 17, and 4 months, respectively, and a fifth patient has secondary patency at 24 months. The remaining three patients occluded their stent-grafts with primary patency last confirmed at 0.5, 2.5, and 8 months, respectively; two have stable claudication and one has a nonhealing wound and rest pain, but all have limb salvage to date.
  
  
  CONCLUSIONS
  Combined femoral endarterectomy and endovascular femoral-popliteal stent-grafting provides a viable option for revascularization of flush SFA occlusions with only a minimal groin incision. The technique described in this article allows for a larger number of patients with flush SFA occlusions to be treated primarily with endovascular techniques and helps avoid a traditional common femoral to above-the-knee popliteal prosthetic bypass.
authors.affiliation: Vascular and Endovascular Therapy, Pennsylvania Hospital, Philadelphia, PA, USA.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Hayes
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Dougherty
authors.forename: Keith D
authors.initials: KD
authors.lastname: Calligaro
mesh_terms: D015901:Angiography, Digital Subtraction; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D055109:Ankle Brachial Index; D001157:Arterial Occlusive Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D003131:Combined Modality Therapy; D003251:Constriction, Pathologic; D004691:Endarterectomy / Q000009:adverse effects / Q000401:mortality; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D023821:Limb Salvage; D015143:Philadelphia; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology; D011474:Prosthesis Design; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex