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The Underestimated Advantages of Iliofemoral Endarterectomy
The Underestimated Advantages of Iliofemoral Endarterectomy Didier Mellie`re, MD, Alejandro Espejel Blancas, MD, Pascal Desgranges, MD, and Jean-Pierre Becquemin, MD, Cre´teil, France
Iliofemoral endarterectomy was invented 50 years ago, but it is seldom practiced today for two reasons. The first is that it is technically challenging and the second is that outcome in early series was poor. Our preliminary experience having been more encouraging, we have continued to perform iliofemoral endarterectomy for the past 20 years. The purpose of this retrospective study was to evaluate our results and compare them with results of alternative techniques described in recent literature. We have performed a total of 176 iliofemoral endarterectomies in patients with normal or nearly normal aortas. The procedure involved the entire network including the common iliac artery, external iliac artery, and common femoral artery in 108 cases (group I), the common iliac artery with or without the external iliac artery in 40 cases (group II), and the external iliac arteries and the common femoral artery with or without the deep femoral artery in 28 cases (group III). From our results we conclude that iliofemoral endarterectomy should be used as a first-choice modality in patients with normal or nearly normal aortas who present with iliac lesions that are either too long for balloon angioplasty or impossible to recanalize. It eliminates the risk of graft infection and false aneurysm. Restenosis can be treated by balloon angioplasty. It also saves the cost of a prosthesis. (Ann Vasc Surg 2000;14:343-349.) DOI: 10.1007/s100169910068
INTRODUCTION The first thromboendarterectomy was performed more than half a century ago in 1947 by Cid Dos Santos.1,2 The original technique was refined by Wylie in 1952.3 Prostheses became available shortly thereafter, but for almost a decade endarterectomy remained the procedure of choice for aortoiliofemoral revascularization. Early prosthetic grafts deteriorated with time. Some type of suture material, e.g., silk, stretched and the tension necessary for placement of crimped prostheses led to false aneurysm. With the advent of Dacron prosthesis and more reliable suture threads, endarterectomy was progressively abandoned.4–6 At the Massachusetts
From the Service de Chirurgie Vasculaire, Hoˆpital Henri Mondor, Cre´teil, France. Correspondence to: D. Mellie`re, MD, Service de Chirurgie Vasculaire, Hoˆpital Henri Mondor, 94010 Cre´teil Ce´dex, France.
General Hospital in 1963, 90% of aortofemoral revascularizations were performed by endarterectomy and 10% by prosthetic bypass. By 1975, these proportions were reversed.5 The same trend was observed at out institution. However, as our experience with iliofemoral endarterectomy was more successful,7 we continued its use in some patients presenting with unilateral iliofemoral obstruction with a normal aorta. This retrospective study of long-term results in these patients was undertaken to compare the efficacy of iliofemoral endarterectomy and other techniques of iliofemoral revascularization. Indeed, 50 years after the invention of iliofemoral endarterectomy, there is currently a revival of interest in this technique for some indications.
PATIENTS AND METHODS Over a period of 20 years (1977-1996), a total of 176 iliofemoral endarterectomies were performed in 343
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162 patients presenting with high-grade stenosis or occlusion of the iliac artery with normal or nearly normal aortas. There were 152 men and 10 women with a mean age of 58.4 years (range, 39 to 91 years). The indication for operative treatment was severe intermittent claudication in 129 patients, unrelenting rest pain in 20 patients, skin ulceration in 21 patients, and acute ischemia in 6 patients. Conventional risk factors were present in all patients, including smoking in 91.5%. Nineteen percent had undergone previous revascularization procedures, including balloon angioplasty of the same artery in three cases. The superficial femoral artery was patent in 45% of cases and occluded in 55%. Endarterectomy was associated with lumbar sympathectomy (performed routinely at the beginning of this series and only occasionally thereafter) in 40 cases, crossover femorofemoral bypass in 2 cases, femoropopliteal bypass in 12 cases, and femoral embolectomy in 1 case. Patients were divided into three groups according to the extent of endarterectomy. Group I included 108 patients in whom endarterectomy involved the common iliac artery, external iliac artery, and common femoral artery with or without the deep femoral artery. Group II included 40 patients in whom endarterectomy involved the common iliac artery with or without the external iliac artery but the common femoral artery was left intact. Group III included 28 patients in whom endarterectomy involved the external iliac artery and common femoral artery with or without the deep femoral artery but the common iliac artery was left intact. Exposure was obtained by the retroperitoneal route and through the femoral triangle. In our early experience, retroperitoneal exposure was achieved vertically in continuity with the femoral incision. More recently, it has been achieved obliquely from the tip of the 11th rib to the middle of the umbilicopubic line to avoid eventration by denervation or disunion of the inguinal ligament. Endarterectomy was open at the level of the femoral and common iliac arteries and closed at the level of the external iliac artery. The section eversion method was used only exceptionally for the external iliac artery if palpation of the blindly endarterectomized artery revealed the presence of residual plaque. The arteriotomy at the level of the common iliac artery was closed by direct suture, while those on the common and deep femoral arteries were closed by vein-patch angioplasty. Insofar as possible, patients were reexamined annually during the first few years and every 3 years thereafter. Patency was documented by physical
Annals of Vascular Surgery
examination, duplex, and, when necessary, arteriography. In all three groups, we studied early and late complications and primary, assisted primary, and secondary patency defined according to the criteria of the SVS/ISCVS. Assisted primary patency refers to stenoses of the endarterectomized zone treated by dilatation.8 In group I we also studied the correlation between the outcome of endarterectomy and circulatory status (patent or occluded) of the superficial femoral artery.
RESULTS Five patients (3%) died within 1 month after endarterectomy. The causes of death were respiratory insufficiency in two cases, myocardial infarction in two cases, and multiple organ failure in one case. Systemic complications included respiratory infection in three cases and infectious shock in one case. Local complications included six thromboses. In three cases, thrombosis was successfully treated by thrombectomy. In the remaining three cases thrombosis was treated by bypass, with two failures followed by amputation. Infection in the femoral triangle occurred in five cases with no adverse vascular repercussions. Reoperation was required for local hemorrhage in four cases (including one case of suture dehiscence involving patch angioplasty on the femoral artery treated by iliofemoral bypass). Ureteral damage occurred in one case and was treated by placement of a J-catheter. Prolonged lymphorrhea involving the femoral triangle was observed in one case. In group I (n = 108), amputation was required in three cases, balloon angioplasty of the endarterectomized zone in three cases, thrombectomy in one case, and aorto- or iliofemoral bypass in four cases. The respective primary (Table I), assisted primary, and secondary patency rates were 96, 96, and 97% at 1 year; 93, 95, and 96% at 5 years; 87, 89, and 91% at 10 years; and 75, 81, and 82% at 15 years (Fig. 1). Limb salvage rates at 10 and 15 years were 98 and 89%, respectively. The mean duration of follow-up was 7.1 years (range, 1 month to 19 years). In group II (n = 40), thrombectomy was required in one case (successful), amputation in two cases, and bypass for thrombosis in six cases. Respective primary (Table II) and secondary patency rates were 87 and 89% at 1 year, 84 and 86% at 5 years, and 80 and 82% at both 10 and 15 years. Limb salvage rates were 97% at 1 year and 93% at 5, 10, and 15 years (Fig. 2). The mean duration of followup was 5.2 years (range, 1 month to 17 years).
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Table I. Primary patency rate in group I in which endarterectomy involved the common iliac, external iliac, and common femoral arteries Exclusions Interval
Revascularizations exposed to risk
Occlusion or stenosis
Insufficient follow-up
Lost from follow-up
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19
108 88 76 73 70 65 58 50 47 40 35 25 18 11 8 7 6 2 1
4 2 0 1 0 0 2 0 1 0 0 1 0 1 0 0 0 0 0
10 8 3 1 3 7 5 3 6 5 8 6 7 2 1 1 4 1 1
0 2 0 0 1 0 1 0 0 0 2 0 0 0 0 0 0 0 0
Died
Cumulative patency (%)
Interim patency (%)
Standard error
6 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0.96 0.98 1.00 0.99 1.00 1.00 0.96 1.00 0.98 1.00 1.00 0.95 1.00 0.9 1.00 1.00 1.00 1.00 1.00
100 96 94 94 93 93 93 89 89 87 87 87 83 83 75 75 75 75 75
0 1.8 2.8 2.8 3.1 3.2 3.4 4.3 4.4 5.2 5.6 6.7 8.3 10.6 13.4 14.3 15.4 26.8 37.9
tion of patency and salvage rates (Fig. 3). The mean duration of follow-up was 3.0 years (range, 1 month to 17 years). Correlation between the outcome of endarterectomy and status of the superficial femoral artery could only be studied in group I because of the small size of groups II and III. Primary patency rates at 1, 5, and 10 years were 94, 91, 86%, respectively, for patients with patent superficial femoral arteries vs. 97, 93, and 87%, respectively, for patients with occluded superficial femoral arteries. The differences were not significant. Only one false aneurysm was observed during follow-up. It occurred 13 years after endarterectomy and was due to distension of patch angioplasty on the femoral artery. It was treated by bypass from the external iliac artery to the deep femoral artery.
Fig. 1. Primary (—), assisted primary (-⽧-), and secondary patency (—䊉—) rates and limb salvage rates (+) in group I, in which endarterectomy involved the primary iliac, external iliac, and common femoral arteries. Nonsignificant results due to a high standard error are indicated by dotted lines.
DISCUSSION
In group III (n = 28), amputation was required in two cases and thrombectomy in one case (unsuccessful, followed by bypass). Respective primary patency and limb salvage rates were 88 and 92% at 1 year and 80 and 92% at 5 years (Table III). Group III was too small to allow more long-term calcula-
The three groups in this series were defined according to the extent of lesions. In group I, the entire iliofemoral network was involved while in group II, the end part of the external iliac and common femoral arteries were spread and in group III the common iliac artery was spared. Although this classification resulted in incomparable groups of
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Table II. Primary patency rate in group II in which endarterectomy involved the common iliac artery with or without the external iliac artery Exclusions Interval
Revascularizations exposed to risk
Occlusion or stenosis
Insufficient follow-up
Lost from follow-up
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15
40 31 29 27 22 21 19 17 15 9 6 4 3 3 3
5 1 1 0 0 0 1 0 0 0 0 0 0 0 0
3 0 1 3 1 2 1 2 5 2 2 2 1 0 0
0 1 0 2 0 0 0 0 1 0 0 0 0 0 0
Died
Interim patency (%)
Cumulative patency (%)
Standard error
1 0 0 0 0 0 0 0 0 1 0 0 0 0 0
0.87 0.97 0.96 1.00 1.00 1.00 0.95 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
100 87 84 84 84 84 84 80 80 80 80 80 80 80 80
0 5.6 6.2 6.4 7.1 7.3 7.7 8.6 9.2 11.9 14.6 17.8 20.6 20.6 20.6
Advantages of Endarterectomy
Fig. 2. Primary (—) and secondary (—䊉—) actuarial patency rates and limb salvage rate (+) in group II, in which endarterectomy involved the primary and external iliac artery but the femoral artery was left intact.
unequal size, it was necessary since the extent of endarterectomy must be adapted to the extent of lesions. This study presents the usual drawbacks of retrospecitve studies. It did, however, allow calculation of patency rates with a standard error of not more than 10% at 1 to 13 years for group I, at 9 years for group II, and at 3 years for group III. Excellent results have been obtained in a few patients operated on prior to the period of this study with follow-ups of more than 20 years (Fig. 4), but this group is too small to allow statistical analysis.
The reasons for which endarterectomy was progressively replaced by prosthetic bypass have been described in a number of articles dating back to the 1970s. Gaspard et al.4 showed that endarterectomy for aortoiliofemoral revascularization was not always feasible, carried the risk of arterial injuries, led to greater bleeding, prolonged procedure time, required more experience, had a higher failure rate, and was subject to numerous contraindications (narrow lumen, tortuosity, extensive calcifications, mild damage or previous endarterectomy). In 1978, Brewster and Darling5 compared endarterectomy with prosthetic bypass and observed that the patency rates for endarterectomy were 10% lower at 5 years and 5% lower at 10 years. The same authors also emphasized the greater skill required for endarterectomy. However, unlike our series, these studies included aortobiiliac and biiliofemoral revascularizations. The limitations described above are less applicable to unilateral iliac endarterectomy performed by the retroperitoneal route. Recently, several groups have reported revived interest in iliac endarterectomy.9–11 The results of the present series of endarterectomy must be compared with those obtained with alternative methods of revascularization (Table IV). Reported long-term patency rates for prosthetic iliofemoral and aortofemoral bypass 12–15 are slightly lower than those in this series. Moreover, unlike endarterectomy, these techniques
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Iliofemoral endarterectomy 347
Table III. Primary patency rate in group III in which endarterectomy involved the external iliac and common femoral arteries with or without the deep femoral artery Exclusions Interval
Revascularizations exposed to risk
Occlusion or stenosis
Insufficient follow-up
Lost from follow-up
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15
28 19 13 9 7 5 3 2 2 1 1 1 1 1 1
3 0 1 0 0 0 1 0 0 0 0 0 0 0 0
6 4 3 2 2 1 0 0 1 0 0 0 0 0 0
0 2 0 0 0 1 0 0 0 0 0 0 0 0 0
Fig. 3. Primary actuarial patency rate (—) and limb salvage rate (+) in group II, in which endarterectomy involved the external iliac and common femoral arteries.
carry the double risk of prosthetic infection (1 to 3%) and false aneurysm (2 to 5%). Actuarial data are not available to allow comparison between endarterectomy and vein graft bypass as described by Cormier et al.16 However, it would seem preferable to reserve vein graft material for other indications. Axillofemoral bypass15,17,18 gives much less satisfactory results than endarterectomy and exposes patients to the potential complications of anastomosis to the axillary artery. Crossover femorofemoral bypass using vein grafts or prostheses12,14,17 also gives poorer patency rates than aorto- or iliofemoral bypass or endarterectomy even when used for
Died
Interim patency (%)
Cumulative patency (%)
Standard error
0 0 0 0 0 0 0 0 0 1 0 0 0 0 0
0.88 1.00 0.91 1.00 1.00 1.00 0.67 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
100 88 88 80 80 80 80 55 54 54 54 54 54 54 54
0 7 8.4 11.9 13.5 16 20 25 25 36 36 36 36 36 36
primary revascularization. Another limitation for femorofemoral bypass is that the proximal and distal segment of the contralateral artery must be healthy to avoid ischemia on the donor side due to shunting. Patency rates after balloon angioplasty depend on the location and length of the lesion. In recent studies, patency rates after dilatation of short lesions involving the common iliac artery have been nearly the same as those of aorto- or iliofemoral bypass.19,20 As a result of technical improvements, balloon angioplasty and stenting are now highly effective with low risk and short hospitalization. Our results with iliac endarterectomy are similar to those described by other groups21,22 and to those described in our first report in 1981.7 Patency rates at 5 and 10 years were no lower than those obtained with aorto- or iliofemoral bypass and higher than those obtained with other techniques. Based on these findings, we think that our technique of iliofemoral endarterectomy can be used as a firstline treatment for iliofemoral lesions that are too long for balloon angioplasty or that cannot be recanalized.We are also giving increasing priority to iliac endarterectomy for the following four reasons: 1. With experience, failures, i.e., inability to perform endarterectomy or arterial damage requiring prosthetic reconstruction, have become uncommon so long as the technique is skillfully executed and patients are properly selected.23 Iliac endarterectomy should be contraindicated
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Table IV. Comparison of different techniques of operative treatment for occlusive disease of the common and external iliac arteries in several series in the recent literature Actuarial patency (%) Technique
Aorto- or iliofemoral bypass
Axillofemoral bypass
Femorofemoral bypass
Balloon angioplasty Endarterectomy
Reference 12
Harrington et al., 1992 Van der Vliet et al., 199413 Schneider et al., 199414 Passman et al., 199615 Rutherford et al., 198717 Harrington et al., 199418 Passman et al., 199615 Rutherford et al., 198717 Harrington et al., 199212 Schneider et al., 199414 Johnston, 199319 Becquemin et al., 19817 Becquemin et al., 19817 Vitale and Inahara, 199021 Van den Dungen et al., 199122
5 years
10 years
74.9 87.9 85 8 62 42.3 74 67 52 62 60.2 83.2 86 84.4 83
— 83 — — — — — — — — — 83.5 71.4 65
Fig. 4. Endarterectomy of the right common iliac, external iliac, and common femoral arteries performed in 1975: A preoperative arteriography, B control image at 6
years, C control image at 20 years (indicated after occlusion of the left iliac artery).
in patients in whom the aorta is narrowed or the deep femoral artery is not amendable to improvement by endarterectomy with patch angioplasty of the first centimeters. Endarterectomy should not be attempted if surgical exposure reveals hardened calcifications extending into the aorta (rare in our experience). Conversely, endarterectomy can be performed after balloon angioplasty and even stent placement.
2. Endarterectomized arteries are more likely than prostheses to remain patent in patients in whom the deep femoral artery is in fair condition and the superficial femoral artery is occluded. This advantage is due to the better compliance of endarterectomized tissue and to the absence of anastomosis between the prosthesis and the diseased deep femoral artery. 3. Skillful endarterectomy eliminates the long-
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term risk of prosthetic infection and false aneurysm. In the case of restenosis, endarterectomized arteries can be treated by percutaneous balloon angioplasty and, if necessary, stent placement. 4. Because a prosthesis need not be used, endarterectomy is a more cost-effective method in these times of increasing health insurance restrictions. In conclusion, our experience shows that with proper patient selection and skillful technique, the outcome of endarterectomy can be as good as with alternative techniques. Since this method eliminates risks of infection, it is particularly indicated for patients who are undernourished or present special septic risks. Because there is no risk of false aneurysm, endarterectomy can be used in young patients. Because vascular compliance is preserved, endartectomy is indicated for young women with narrow arteries. Another advantage of this technique is saving the cost of a prosthesis. Thus, 50 years after its invention, endarterectomy deserves to be taught and used. REFERENCES 1. Dos Santos JC. Sur la de´sobstruction des thrombus arte´riels anciens. Mem Acad Chir 1947;73:409-411. 2. Dos Santos JC. Late results of reconstructive arterial surgery (restoration, disobliteration, replacement with the establishment of some operative principles). J Cardiovasc Surg 1964; 5:445-462. 3. Wylie EJ. Thromboendarterectomy for arteriosclerotic thromboses of major arteries. Surgery 1952;32:275-292. 4. Gaspard DJ, Cohen JL, Gaspar MR. Aortoiliofemoral thromboendarterectomy vs bypass graft: a randomized study. Arch Surg 1972;105:898-901. 5. Brewster DC, Darling RC. Optimal methods of aortoiliac reconstruction. Surgery 1978;84:739-748. 6. Szilagyi DE, Elliott JP, Smith RF, et al. A thirty-year survey of the reconstructive surgical treatment of aortoiliac occlusive disease. J Vasc Surg 1986;3:421-436. 7. Becquemin JP, Mellie`re D, Danis RK, et al. L’endarte´riectomie pour traitement d’oblite´rations iliaques e´tendues. J Mal Vasc 1981;6:285-288.
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8. Nehler MR, Moneta GL, Yeager RA, et al. Surgical treatment of threatened reversed infrainguinal vein grafts. J Vasc Surg 1994;20:558-565. 9. Oertli D, Wigger P, Landmann J, et al. Long-term results after open and semiclosed thromboendartectomy for aortoiliac occlusive disease. Eur J Vasc Endovasc Surg 1996;11: 432-436. 10. Oskam J, Van den Dungen J, Boontje AH. Thromboendarterectomy for obstructive disease of common iliac artery. Cardiovasc Surg 1996;4:356-359. 11. Royle J, Somjen G, Tong Y. Combined semiclosed iliac endarterectomy and distal arterial reconstruction for multilevel arterial disease. Cardiovasc Surg 1996;4:360-363. 12. Harrington ME, Harrington EB, Haimov M, et al. Iliofemoral versus femorofemoral bypass: the case for an individualized approach. J Vasc Surg 1992;16:841-854. 13. Van der Vliet J, Scharn DM, De Waard J, et al. Unilateral vascular reconstruction for iliac obstructive disease. J Vasc Surg 1994;19:610-614. 14. Schneider J, Besso S, Walsh D, et al. Femorofemoral versus aortobifemoral bypass outcome and hemodynamic results. J Vasc Surg 1994;19:43-57. 15. Passman M, Taylor L, Moneta G, et al. Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease. J Vasc Surg 1996;23:263-271. 16. Cormier JM, Lagneau P, Firouzabadie H. Greffes veineuses aorto-ilio-fe´morales. J Chir (Paris) 1977;6:397-412. 17. Rutherford R, Patt A, Pearce W. Extra-anatomic bypass: a closer view. J Vasc Surg 1987;6:437-446. 18. Harrington M, Harrington E, Haimov M, et al. Axillofemoral bypass: a compromised bypass for compromised patients. J Vasc Surg 1994;20:195-201. 19. Johnston W. Iliac arteries: reanalysis of results of balloon angioplasty. Radiology 1993;186:207-212. 20. Becquemin JP, Qvarfordt P, Desgranges P, et al. Surgical transluminal iliac angioplasty with selective stenting: longterm results assessed by means of duplex-scan. J Vasc Surg 1999;29:422-429. 21. Vitale G, Inahara T. Extraperitoneal endarterectomy for iliofemoral occlusive disease. J Vasc Surg 1990;12:409-415. 22. Van den Dungen J, Boontje A, Kropveld A. Unilateral iliofemoral occlusive disease: long-term results of the semiclosed: endarterectomy with the ringstripper. J Vasc Surg 1991;14:673-677. 23. Mellie`re D, Espegel Blancas A, Desgranges P, et al. Occlusious iliofe´morales unilaterals: l’endarte´riectomie pour hydrodissection procure les meilleurs re´sultats a` long terme. J Cardiovasc Surg 1998;39:117-123.
Iliofemoral endarterectomy was invented 50 years ago, but it is seldom practiced today for two reasons. The first is that it is technically challenging and the second is that outcome in early series was poor. Our preliminary experience having been more encouraging, we have continued to perform iliofemoral endarterectomy for the past 20 years. The purpose of this retrospective study was to evaluate our results and compare them with results of alternative techniques described in recent literature. We have performed a total of 176 iliofemoral endarterectomies in patients with normal or nearly normal aortas. The procedure involved the entire network including the common iliac artery, external iliac artery, and common femoral artery in 108 cases (group I), the common iliac artery with or without the external iliac artery in 40 cases (group II), and the external iliac arteries and the common femoral artery with or without the deep femoral artery in 28 cases (group III). From our results we conclude that iliofemoral endarterectomy should be used as a first-choice modality in patients with normal or nearly normal aortas who present with iliac lesions that are either too long for balloon angioplasty or impossible to recanalize. It eliminates the risk of graft infection and false aneurysm. Restenosis can be treated by balloon angioplasty. It also saves the cost of a prosthesis. (Ann Vasc Surg 2000;14:343-349.) DOI: 10.1007/s100169910068
INTRODUCTION The first thromboendarterectomy was performed more than half a century ago in 1947 by Cid Dos Santos.1,2 The original technique was refined by Wylie in 1952.3 Prostheses became available shortly thereafter, but for almost a decade endarterectomy remained the procedure of choice for aortoiliofemoral revascularization. Early prosthetic grafts deteriorated with time. Some type of suture material, e.g., silk, stretched and the tension necessary for placement of crimped prostheses led to false aneurysm. With the advent of Dacron prosthesis and more reliable suture threads, endarterectomy was progressively abandoned.4–6 At the Massachusetts
From the Service de Chirurgie Vasculaire, Hoˆpital Henri Mondor, Cre´teil, France. Correspondence to: D. Mellie`re, MD, Service de Chirurgie Vasculaire, Hoˆpital Henri Mondor, 94010 Cre´teil Ce´dex, France.
General Hospital in 1963, 90% of aortofemoral revascularizations were performed by endarterectomy and 10% by prosthetic bypass. By 1975, these proportions were reversed.5 The same trend was observed at out institution. However, as our experience with iliofemoral endarterectomy was more successful,7 we continued its use in some patients presenting with unilateral iliofemoral obstruction with a normal aorta. This retrospective study of long-term results in these patients was undertaken to compare the efficacy of iliofemoral endarterectomy and other techniques of iliofemoral revascularization. Indeed, 50 years after the invention of iliofemoral endarterectomy, there is currently a revival of interest in this technique for some indications.
PATIENTS AND METHODS Over a period of 20 years (1977-1996), a total of 176 iliofemoral endarterectomies were performed in 343
344
Mellie`re et al.
162 patients presenting with high-grade stenosis or occlusion of the iliac artery with normal or nearly normal aortas. There were 152 men and 10 women with a mean age of 58.4 years (range, 39 to 91 years). The indication for operative treatment was severe intermittent claudication in 129 patients, unrelenting rest pain in 20 patients, skin ulceration in 21 patients, and acute ischemia in 6 patients. Conventional risk factors were present in all patients, including smoking in 91.5%. Nineteen percent had undergone previous revascularization procedures, including balloon angioplasty of the same artery in three cases. The superficial femoral artery was patent in 45% of cases and occluded in 55%. Endarterectomy was associated with lumbar sympathectomy (performed routinely at the beginning of this series and only occasionally thereafter) in 40 cases, crossover femorofemoral bypass in 2 cases, femoropopliteal bypass in 12 cases, and femoral embolectomy in 1 case. Patients were divided into three groups according to the extent of endarterectomy. Group I included 108 patients in whom endarterectomy involved the common iliac artery, external iliac artery, and common femoral artery with or without the deep femoral artery. Group II included 40 patients in whom endarterectomy involved the common iliac artery with or without the external iliac artery but the common femoral artery was left intact. Group III included 28 patients in whom endarterectomy involved the external iliac artery and common femoral artery with or without the deep femoral artery but the common iliac artery was left intact. Exposure was obtained by the retroperitoneal route and through the femoral triangle. In our early experience, retroperitoneal exposure was achieved vertically in continuity with the femoral incision. More recently, it has been achieved obliquely from the tip of the 11th rib to the middle of the umbilicopubic line to avoid eventration by denervation or disunion of the inguinal ligament. Endarterectomy was open at the level of the femoral and common iliac arteries and closed at the level of the external iliac artery. The section eversion method was used only exceptionally for the external iliac artery if palpation of the blindly endarterectomized artery revealed the presence of residual plaque. The arteriotomy at the level of the common iliac artery was closed by direct suture, while those on the common and deep femoral arteries were closed by vein-patch angioplasty. Insofar as possible, patients were reexamined annually during the first few years and every 3 years thereafter. Patency was documented by physical
Annals of Vascular Surgery
examination, duplex, and, when necessary, arteriography. In all three groups, we studied early and late complications and primary, assisted primary, and secondary patency defined according to the criteria of the SVS/ISCVS. Assisted primary patency refers to stenoses of the endarterectomized zone treated by dilatation.8 In group I we also studied the correlation between the outcome of endarterectomy and circulatory status (patent or occluded) of the superficial femoral artery.
RESULTS Five patients (3%) died within 1 month after endarterectomy. The causes of death were respiratory insufficiency in two cases, myocardial infarction in two cases, and multiple organ failure in one case. Systemic complications included respiratory infection in three cases and infectious shock in one case. Local complications included six thromboses. In three cases, thrombosis was successfully treated by thrombectomy. In the remaining three cases thrombosis was treated by bypass, with two failures followed by amputation. Infection in the femoral triangle occurred in five cases with no adverse vascular repercussions. Reoperation was required for local hemorrhage in four cases (including one case of suture dehiscence involving patch angioplasty on the femoral artery treated by iliofemoral bypass). Ureteral damage occurred in one case and was treated by placement of a J-catheter. Prolonged lymphorrhea involving the femoral triangle was observed in one case. In group I (n = 108), amputation was required in three cases, balloon angioplasty of the endarterectomized zone in three cases, thrombectomy in one case, and aorto- or iliofemoral bypass in four cases. The respective primary (Table I), assisted primary, and secondary patency rates were 96, 96, and 97% at 1 year; 93, 95, and 96% at 5 years; 87, 89, and 91% at 10 years; and 75, 81, and 82% at 15 years (Fig. 1). Limb salvage rates at 10 and 15 years were 98 and 89%, respectively. The mean duration of follow-up was 7.1 years (range, 1 month to 19 years). In group II (n = 40), thrombectomy was required in one case (successful), amputation in two cases, and bypass for thrombosis in six cases. Respective primary (Table II) and secondary patency rates were 87 and 89% at 1 year, 84 and 86% at 5 years, and 80 and 82% at both 10 and 15 years. Limb salvage rates were 97% at 1 year and 93% at 5, 10, and 15 years (Fig. 2). The mean duration of followup was 5.2 years (range, 1 month to 17 years).
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Table I. Primary patency rate in group I in which endarterectomy involved the common iliac, external iliac, and common femoral arteries Exclusions Interval
Revascularizations exposed to risk
Occlusion or stenosis
Insufficient follow-up
Lost from follow-up
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19
108 88 76 73 70 65 58 50 47 40 35 25 18 11 8 7 6 2 1
4 2 0 1 0 0 2 0 1 0 0 1 0 1 0 0 0 0 0
10 8 3 1 3 7 5 3 6 5 8 6 7 2 1 1 4 1 1
0 2 0 0 1 0 1 0 0 0 2 0 0 0 0 0 0 0 0
Died
Cumulative patency (%)
Interim patency (%)
Standard error
6 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0.96 0.98 1.00 0.99 1.00 1.00 0.96 1.00 0.98 1.00 1.00 0.95 1.00 0.9 1.00 1.00 1.00 1.00 1.00
100 96 94 94 93 93 93 89 89 87 87 87 83 83 75 75 75 75 75
0 1.8 2.8 2.8 3.1 3.2 3.4 4.3 4.4 5.2 5.6 6.7 8.3 10.6 13.4 14.3 15.4 26.8 37.9
tion of patency and salvage rates (Fig. 3). The mean duration of follow-up was 3.0 years (range, 1 month to 17 years). Correlation between the outcome of endarterectomy and status of the superficial femoral artery could only be studied in group I because of the small size of groups II and III. Primary patency rates at 1, 5, and 10 years were 94, 91, 86%, respectively, for patients with patent superficial femoral arteries vs. 97, 93, and 87%, respectively, for patients with occluded superficial femoral arteries. The differences were not significant. Only one false aneurysm was observed during follow-up. It occurred 13 years after endarterectomy and was due to distension of patch angioplasty on the femoral artery. It was treated by bypass from the external iliac artery to the deep femoral artery.
Fig. 1. Primary (—), assisted primary (-⽧-), and secondary patency (—䊉—) rates and limb salvage rates (+) in group I, in which endarterectomy involved the primary iliac, external iliac, and common femoral arteries. Nonsignificant results due to a high standard error are indicated by dotted lines.
DISCUSSION
In group III (n = 28), amputation was required in two cases and thrombectomy in one case (unsuccessful, followed by bypass). Respective primary patency and limb salvage rates were 88 and 92% at 1 year and 80 and 92% at 5 years (Table III). Group III was too small to allow more long-term calcula-
The three groups in this series were defined according to the extent of lesions. In group I, the entire iliofemoral network was involved while in group II, the end part of the external iliac and common femoral arteries were spread and in group III the common iliac artery was spared. Although this classification resulted in incomparable groups of
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Table II. Primary patency rate in group II in which endarterectomy involved the common iliac artery with or without the external iliac artery Exclusions Interval
Revascularizations exposed to risk
Occlusion or stenosis
Insufficient follow-up
Lost from follow-up
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15
40 31 29 27 22 21 19 17 15 9 6 4 3 3 3
5 1 1 0 0 0 1 0 0 0 0 0 0 0 0
3 0 1 3 1 2 1 2 5 2 2 2 1 0 0
0 1 0 2 0 0 0 0 1 0 0 0 0 0 0
Died
Interim patency (%)
Cumulative patency (%)
Standard error
1 0 0 0 0 0 0 0 0 1 0 0 0 0 0
0.87 0.97 0.96 1.00 1.00 1.00 0.95 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
100 87 84 84 84 84 84 80 80 80 80 80 80 80 80
0 5.6 6.2 6.4 7.1 7.3 7.7 8.6 9.2 11.9 14.6 17.8 20.6 20.6 20.6
Advantages of Endarterectomy
Fig. 2. Primary (—) and secondary (—䊉—) actuarial patency rates and limb salvage rate (+) in group II, in which endarterectomy involved the primary and external iliac artery but the femoral artery was left intact.
unequal size, it was necessary since the extent of endarterectomy must be adapted to the extent of lesions. This study presents the usual drawbacks of retrospecitve studies. It did, however, allow calculation of patency rates with a standard error of not more than 10% at 1 to 13 years for group I, at 9 years for group II, and at 3 years for group III. Excellent results have been obtained in a few patients operated on prior to the period of this study with follow-ups of more than 20 years (Fig. 4), but this group is too small to allow statistical analysis.
The reasons for which endarterectomy was progressively replaced by prosthetic bypass have been described in a number of articles dating back to the 1970s. Gaspard et al.4 showed that endarterectomy for aortoiliofemoral revascularization was not always feasible, carried the risk of arterial injuries, led to greater bleeding, prolonged procedure time, required more experience, had a higher failure rate, and was subject to numerous contraindications (narrow lumen, tortuosity, extensive calcifications, mild damage or previous endarterectomy). In 1978, Brewster and Darling5 compared endarterectomy with prosthetic bypass and observed that the patency rates for endarterectomy were 10% lower at 5 years and 5% lower at 10 years. The same authors also emphasized the greater skill required for endarterectomy. However, unlike our series, these studies included aortobiiliac and biiliofemoral revascularizations. The limitations described above are less applicable to unilateral iliac endarterectomy performed by the retroperitoneal route. Recently, several groups have reported revived interest in iliac endarterectomy.9–11 The results of the present series of endarterectomy must be compared with those obtained with alternative methods of revascularization (Table IV). Reported long-term patency rates for prosthetic iliofemoral and aortofemoral bypass 12–15 are slightly lower than those in this series. Moreover, unlike endarterectomy, these techniques
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Iliofemoral endarterectomy 347
Table III. Primary patency rate in group III in which endarterectomy involved the external iliac and common femoral arteries with or without the deep femoral artery Exclusions Interval
Revascularizations exposed to risk
Occlusion or stenosis
Insufficient follow-up
Lost from follow-up
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15
28 19 13 9 7 5 3 2 2 1 1 1 1 1 1
3 0 1 0 0 0 1 0 0 0 0 0 0 0 0
6 4 3 2 2 1 0 0 1 0 0 0 0 0 0
0 2 0 0 0 1 0 0 0 0 0 0 0 0 0
Fig. 3. Primary actuarial patency rate (—) and limb salvage rate (+) in group II, in which endarterectomy involved the external iliac and common femoral arteries.
carry the double risk of prosthetic infection (1 to 3%) and false aneurysm (2 to 5%). Actuarial data are not available to allow comparison between endarterectomy and vein graft bypass as described by Cormier et al.16 However, it would seem preferable to reserve vein graft material for other indications. Axillofemoral bypass15,17,18 gives much less satisfactory results than endarterectomy and exposes patients to the potential complications of anastomosis to the axillary artery. Crossover femorofemoral bypass using vein grafts or prostheses12,14,17 also gives poorer patency rates than aorto- or iliofemoral bypass or endarterectomy even when used for
Died
Interim patency (%)
Cumulative patency (%)
Standard error
0 0 0 0 0 0 0 0 0 1 0 0 0 0 0
0.88 1.00 0.91 1.00 1.00 1.00 0.67 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
100 88 88 80 80 80 80 55 54 54 54 54 54 54 54
0 7 8.4 11.9 13.5 16 20 25 25 36 36 36 36 36 36
primary revascularization. Another limitation for femorofemoral bypass is that the proximal and distal segment of the contralateral artery must be healthy to avoid ischemia on the donor side due to shunting. Patency rates after balloon angioplasty depend on the location and length of the lesion. In recent studies, patency rates after dilatation of short lesions involving the common iliac artery have been nearly the same as those of aorto- or iliofemoral bypass.19,20 As a result of technical improvements, balloon angioplasty and stenting are now highly effective with low risk and short hospitalization. Our results with iliac endarterectomy are similar to those described by other groups21,22 and to those described in our first report in 1981.7 Patency rates at 5 and 10 years were no lower than those obtained with aorto- or iliofemoral bypass and higher than those obtained with other techniques. Based on these findings, we think that our technique of iliofemoral endarterectomy can be used as a firstline treatment for iliofemoral lesions that are too long for balloon angioplasty or that cannot be recanalized.We are also giving increasing priority to iliac endarterectomy for the following four reasons: 1. With experience, failures, i.e., inability to perform endarterectomy or arterial damage requiring prosthetic reconstruction, have become uncommon so long as the technique is skillfully executed and patients are properly selected.23 Iliac endarterectomy should be contraindicated
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Table IV. Comparison of different techniques of operative treatment for occlusive disease of the common and external iliac arteries in several series in the recent literature Actuarial patency (%) Technique
Aorto- or iliofemoral bypass
Axillofemoral bypass
Femorofemoral bypass
Balloon angioplasty Endarterectomy
Reference 12
Harrington et al., 1992 Van der Vliet et al., 199413 Schneider et al., 199414 Passman et al., 199615 Rutherford et al., 198717 Harrington et al., 199418 Passman et al., 199615 Rutherford et al., 198717 Harrington et al., 199212 Schneider et al., 199414 Johnston, 199319 Becquemin et al., 19817 Becquemin et al., 19817 Vitale and Inahara, 199021 Van den Dungen et al., 199122
5 years
10 years
74.9 87.9 85 8 62 42.3 74 67 52 62 60.2 83.2 86 84.4 83
— 83 — — — — — — — — — 83.5 71.4 65
Fig. 4. Endarterectomy of the right common iliac, external iliac, and common femoral arteries performed in 1975: A preoperative arteriography, B control image at 6
years, C control image at 20 years (indicated after occlusion of the left iliac artery).
in patients in whom the aorta is narrowed or the deep femoral artery is not amendable to improvement by endarterectomy with patch angioplasty of the first centimeters. Endarterectomy should not be attempted if surgical exposure reveals hardened calcifications extending into the aorta (rare in our experience). Conversely, endarterectomy can be performed after balloon angioplasty and even stent placement.
2. Endarterectomized arteries are more likely than prostheses to remain patent in patients in whom the deep femoral artery is in fair condition and the superficial femoral artery is occluded. This advantage is due to the better compliance of endarterectomized tissue and to the absence of anastomosis between the prosthesis and the diseased deep femoral artery. 3. Skillful endarterectomy eliminates the long-
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term risk of prosthetic infection and false aneurysm. In the case of restenosis, endarterectomized arteries can be treated by percutaneous balloon angioplasty and, if necessary, stent placement. 4. Because a prosthesis need not be used, endarterectomy is a more cost-effective method in these times of increasing health insurance restrictions. In conclusion, our experience shows that with proper patient selection and skillful technique, the outcome of endarterectomy can be as good as with alternative techniques. Since this method eliminates risks of infection, it is particularly indicated for patients who are undernourished or present special septic risks. Because there is no risk of false aneurysm, endarterectomy can be used in young patients. Because vascular compliance is preserved, endartectomy is indicated for young women with narrow arteries. Another advantage of this technique is saving the cost of a prosthesis. Thus, 50 years after its invention, endarterectomy deserves to be taught and used. REFERENCES 1. Dos Santos JC. Sur la de´sobstruction des thrombus arte´riels anciens. Mem Acad Chir 1947;73:409-411. 2. Dos Santos JC. Late results of reconstructive arterial surgery (restoration, disobliteration, replacement with the establishment of some operative principles). J Cardiovasc Surg 1964; 5:445-462. 3. Wylie EJ. Thromboendarterectomy for arteriosclerotic thromboses of major arteries. Surgery 1952;32:275-292. 4. Gaspard DJ, Cohen JL, Gaspar MR. Aortoiliofemoral thromboendarterectomy vs bypass graft: a randomized study. Arch Surg 1972;105:898-901. 5. Brewster DC, Darling RC. Optimal methods of aortoiliac reconstruction. Surgery 1978;84:739-748. 6. Szilagyi DE, Elliott JP, Smith RF, et al. A thirty-year survey of the reconstructive surgical treatment of aortoiliac occlusive disease. J Vasc Surg 1986;3:421-436. 7. Becquemin JP, Mellie`re D, Danis RK, et al. L’endarte´riectomie pour traitement d’oblite´rations iliaques e´tendues. J Mal Vasc 1981;6:285-288.
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8. Nehler MR, Moneta GL, Yeager RA, et al. Surgical treatment of threatened reversed infrainguinal vein grafts. J Vasc Surg 1994;20:558-565. 9. Oertli D, Wigger P, Landmann J, et al. Long-term results after open and semiclosed thromboendartectomy for aortoiliac occlusive disease. Eur J Vasc Endovasc Surg 1996;11: 432-436. 10. Oskam J, Van den Dungen J, Boontje AH. Thromboendarterectomy for obstructive disease of common iliac artery. Cardiovasc Surg 1996;4:356-359. 11. Royle J, Somjen G, Tong Y. Combined semiclosed iliac endarterectomy and distal arterial reconstruction for multilevel arterial disease. Cardiovasc Surg 1996;4:360-363. 12. Harrington ME, Harrington EB, Haimov M, et al. Iliofemoral versus femorofemoral bypass: the case for an individualized approach. J Vasc Surg 1992;16:841-854. 13. Van der Vliet J, Scharn DM, De Waard J, et al. Unilateral vascular reconstruction for iliac obstructive disease. J Vasc Surg 1994;19:610-614. 14. Schneider J, Besso S, Walsh D, et al. Femorofemoral versus aortobifemoral bypass outcome and hemodynamic results. J Vasc Surg 1994;19:43-57. 15. Passman M, Taylor L, Moneta G, et al. Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease. J Vasc Surg 1996;23:263-271. 16. Cormier JM, Lagneau P, Firouzabadie H. Greffes veineuses aorto-ilio-fe´morales. J Chir (Paris) 1977;6:397-412. 17. Rutherford R, Patt A, Pearce W. Extra-anatomic bypass: a closer view. J Vasc Surg 1987;6:437-446. 18. Harrington M, Harrington E, Haimov M, et al. Axillofemoral bypass: a compromised bypass for compromised patients. J Vasc Surg 1994;20:195-201. 19. Johnston W. Iliac arteries: reanalysis of results of balloon angioplasty. Radiology 1993;186:207-212. 20. Becquemin JP, Qvarfordt P, Desgranges P, et al. Surgical transluminal iliac angioplasty with selective stenting: longterm results assessed by means of duplex-scan. J Vasc Surg 1999;29:422-429. 21. Vitale G, Inahara T. Extraperitoneal endarterectomy for iliofemoral occlusive disease. J Vasc Surg 1990;12:409-415. 22. Van den Dungen J, Boontje A, Kropveld A. Unilateral iliofemoral occlusive disease: long-term results of the semiclosed: endarterectomy with the ringstripper. J Vasc Surg 1991;14:673-677. 23. Mellie`re D, Espegel Blancas A, Desgranges P, et al. Occlusious iliofe´morales unilaterals: l’endarte´riectomie pour hydrodissection procure les meilleurs re´sultats a` long terme. J Cardiovasc Surg 1998;39:117-123.