Direct approaches to the distal portions of the deep femoral artery for limb salvage bypasses

Direct approaches to the distal portions of the deep femoral artery for limb salvage bypasses Anselmo A. Nunez, MD,* Frank J. Veith, MD, Paul Collier, MD,** Enrico Ascer, MD, Sheila White Flores, MD, and Sushil K. Gupta, MD, New York, N.Y. This study describes a technique that facilitates lower extremity "redo" revascularizations and that may increase the number o f patients who can be revascularized. By using the distal deep femoral artery for bypass outflow or inflow, we were able to revascularize patients with no other accessible patent major thigh artery, to increase the use o f autologous vein for infrapopliteal bypasses, and to avoid difficult groin reoperations. Thirtyseven patients (23 men) had various distal deep femoral revascularizations for limb salvage indications only (rest pain, ischemic ulcers, a n d / o r gangrene). Techniques to expose the distal deep femoral artery directly are described and their uses discussed. We found that the type o f bypass performed (e.g., axiUofemoral or aortofemoral) determined the patency rate o f the reconstruction. Placement o f the origin or termination o f the graft in the deep femoral artery did not appear to affect the results adversely. (J VAsc SURG 1988;8: 576-81.)

Revascularization of the deep femoral artery (DFA) is an important method of maintaining the viability of an ischemic lower extremity.1 The most common method of DFA revascularization is patch angioplasty. 2 However, arterial bypass grafts that originate or terminate in the proximal DFA are important alternatives to similar uses of the common femoral artery (CFA) and are widely used. 3 In the course of performing secondary arterial reconstructions on patients who had had multiple previous operations on their groin arteries, it became apparent that the surgical approach to these vessels was sometimes hampered by scarring and occasionally by infection. Moreover, it was common to find that the CFA and the proximal DFA were obliterated by prior operations or by progression of atheroscle-

rotic lesions. The standard approach to the often patent, distal portions of the DFA involved tracing the artery from its origin distally. This was often rendered difficult, or impossible, because of prior operative scarring or unresolved wound infection. This prompted us to develop surgical techniques for approaching the distal, previously undissected portions of the DFA directly, through unscarred tissue planes. These distal portions of the DFA could then be used as the site of origin or insertion of a secondary arterial bypass designed to save an ischemic extremity. We describe our initial experience with arterial bypass grafts involving the distal portions of the DFA. Patient selection criteria, a review of the pertinent anatomic details, and the specific surgical techniques used to expose the distal DFA directly are also presented.

From the Division of Vascular Surgery, Montefiore Medical Center--Albert Einstein College of Medicine. Supported in part by a grant from the Manning Foundation. Presented at the First Annual Vascular Fellows' Competition of the Vascular Society of New Jersey, the New York Regional Vascular Society, and the New York Cardiovascular Society, May 16, 1985. Reprint requests: Anselmo A. Nunez, MD, University of Miami School of Medicine, Dept. of Surgery, R-310, P.O. Box 016310, Miami, FL 33101. ~Department of Surgery, University of Miami School of Medicine, Miami, Fla. ~*Department of Surgery, Sewicldey Valley Hospital, Sewicldey, Pa.

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576

At Montefiore Medical Center between January 1981 and April 1985, 37 patients received arterial bypass grafts, which either originated from or terminated in the distal DFA. Sixty-two percent of these patients were men and 52% were diabetic. Their ages ranged from 39 to 86 years (mean 68 years). The operative indication was severe rest pain, nonhealing ischemic ulceration, or gangrene in all 37 patients. For purposes of this study, the distal DFA is defined

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Distal deepfemoral artery bypasses 577

Table I. The types of bypasses performed, categorized by their relationship to the distal deep femoral artery and their routing No.

Outflow group (n = 32) Extraanatomic bypasses Axillary origin Contralateral origin Anatomic bypasses Aorta/CFA origin Aorto-distal DFA-poplitcal sequentials Inflow group (n = 5) Popliteal outflow Infrap0pliteal outflow

20 12 8

moral artery I2

8 4

femoral orfery 5

"ol artery

2 3

luscle as that portion of the artery beyond the origin of the lateral circumflex femoral artery (LCFA). When the LCFA arises from the CFA, then the distal DFA is that segment of the artery beginning 1 cm distal to its origin. Types o f bypasses performed. Various operations were performed on these patients, with the common factor being an anastomosis for either inflow or outflow in the distal DFA. Of the 37 bypasses performed, the distal DFA served as an inflow vessel in five cases (inflow group) and as an outflow artery in 32 cases (outflow group) (Table I). In the outflow group, 20 grafts were routed extraanatomically. Twelve of these bypass grafts originated in the ipsilateral axillary artery whereas eight originated in the contralateral femoral (superficial femoral artery [SFA], DFA, or CFA) or iliac artery. The remaining 12 grafts in the outflow group were routed anatomically, via subfascial tunnels. Seven of these grafts originated from the aorta and one f r o m the ipsilateral CFA. An additional four grafts that originated from the aorta were sequential bypasses in which the distal DFA was the site of the intermediate anastomosis, whereas the distal anastomosis was to the popliteal artery. All bypasses in which the distal DFA served as an outflow tract were performed with 6 mm polytetrafluoroethylene (PTFE) grafts. Four of the bypasses in the inflow group were performed with autologous greater saphenous vein. Criteria for use o f the distal DFA. A distal DFA bypass was performed when at least one of the following conditions existed: 1. Arteriography showed the distal DFA to be the only thigh vessel patent. 2. Multiple prior groin revascularizations had been performed. 3. A history of prior infection in the groin

Fig. 1. Anatomy of the DFA. Note the surface landmarks used to identify the course of the DFA.

wound, especially with subfascial involvement, was obtained. 4. Only a limited length of autologous vein was available for a femoroinfrapopliteal bypass and severe occlusive disease of the SFA was present. ANATOMY OF T H E DFA

The DFA is one of two major terminal branches of the CFA (Fig. 1). It arises laterally from this vessel and follows a posterolateral course to its final location, posterior to the linea aspera of the femur. The origin of the DFA is located 1 to 8.5 cm (mean 5 cm) inferior to the inguinal ligament.4 As shown in Fig. 1, the sartorius muscle serves as the landmark for localization of the DFA. This structure describes an oblique line extending from the anterior superior iliac spine to the midpoint of the medial femoral condyle.

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578 N u n e z et a!.

Common femoral artery Superficial femoral arfery Deep femoral arfery

"- "~ PROXIMALZONE

>MIDDLEZONE Firsf peHorafing Second perforating branch

~ DISTALZONE Third perforating branch - -

Fig. 2. Zones of the DFA. Table II. Use of the deep femoral artery as proximal anastomotic site (inflow group) Operative indication

Level of DF anastomosis Type of operation

DF popliteal bypass DF infrapopliteal bypass

Middle (n = 2)

Distal (n = 3)

RP

1 1

1 2

1 0

Mortality Tissueloss rate (%)

i 3

0 0

Amputation rate (%)

Follow-up~ (mo)

latency rate at 18 mo (%)

50 (1)t 0

8-18 1-8

50 100:~

DF, Distal deep femoral; RP, rest pain. *Expressed as range. t Number of patients in parenthesis. :~Patency at 6 months.

The DFA can be divided into three zones (Fig. 2). This division is based on anatomic landmarks, surgical approach, and distribution of atherosclerosis. The p r o x i m a l zone extends from the origin of the DFA to the origin of the LCFA. This is the proximal DFA. The distal region of the DFA is divided into two zones. The middle zone extends from the LCFA to the second perforating branch and lies within the distal femoral triangle. The distal zone is the area beyond the second perforating branch, lying distal to the apex of the femoral triangle. This segment of the artery lies between the adductors longus and magnus (Figs. 3 and 4). At operation, an incision is made overlying the

region of the DFA to be exposed and is located to avoid previous thigh incisions. This technique allows dissection through unscarred and uninfected tissue planes. The incision may be made along either the medial or lateral border of the sartorius muscle (Fig. 3). The lateral approach is particularly useful when there is medial thigh scarring or infection. Exposure o f the middle zone. The sartorius muscle is retracted laterally or medially along with the underlying superficial femoral neurovascular btuldie (Figs. 3 and 4). No attempt is made to identify or dissect the SFA. A discrete, dense connective tissue membrane, extending from the adductor longus to the vastus medialis, is then identified and longitudinally incised for several centimeters (Fig. 3). If a

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Distal deep femoral artery bypasses 579

Pectineus m. Adductor brevis m.

,,I

femoral arhery s medialis m. U$ I11. m.

Fig. 3. Technique for direct approach to the distal DFA, without exposure of CFA or SFA. Inset shows location of medial skin incision for exposure of the middle and distal zones (solid line). Alternatively, an incision lateral to the sartorius muscle may be made and this muscle retracted medially (dashed line). This is particularly useful if scarring and infection are present medially in the thigh.

Table I I I . Use o f the deep femoral artery as distal anastomotic site (outflow group) Operative indication

Level of DF anastomosis Type of operation

Middle (n = 22)

Distal (n = 10)

RP

Axillo-DF bypass Femoro-DF bypass Aorto-CF-DF Aorto-CF-DF-popliteal

8 5 6 3

4 3 2 1

10 6 5 3

Mortality Amputation Tissue loss rate (%) rate (%)

2 2 3 1

25 (3)t 0 0 0

25 (3) 0 13 (1) 0

Follow-up~ (mo)

Patency rate at 24 mo (%)

5-30 1-24 3-31 2-27

52 88 75 100

For abbreviations see Table II. ~Expressed as range. t Number of patients in parentheses.

pulse is present in the DFA, it will usually be palpable either through this intact membrane or after it is divided. Once this membrane has been incised, the D F A can be located, even when pulseless, by locating one o f its more superficial accompanying veins and

dissecting deep to the vein. When the proximal portion o f the middle zone must be exposed, the overlying lateral circumflex femoral vein must be divided and ligatedl E x p o s u r e o f the distal zone. One o f two tech-

580

~ u n e z Ct al.

Fig. 4. Transverse section of the thigh (viewed from above) shows plane of dissection when the anterior-medial approach (solid arrow) is used. Alternatively, the DFA can be approached through an even more anterior route (dashed arrow) by an incision along the lateral border of the sartorins and retracting this muscle and the superficial femoral neurovascular bundle medially to reach the distal DFA.

niques may be used to expose the distal zone of the DFA directly. Both approaches involve a cutaneous incision along the border of the sartorius muscle, distal to the apex of the femoral triangle. When the first technique (anterior approach) is used, the lower extremity is positioned with the hip slightly flexed, abducted and externally rotated, with the knee moderately flexed. Dissection proceeds along the medial or lateral border of the sartorius muscle until the adductor longus is identified (Fig. 4). The fibers of the latter muscle are longitudinally separated from the vastus mcdialis muscle by incising the dense fibrous connection between the two musdes, thereby exposing the DFA, as described above. Use of the second technique, or posterior approach, often requires more pronounced abduction and lateral rotation of the thigh than usual. Furthermore, to place the field of dissection closer to the coronal plane, the operating table should be rotated towards the side being operated on. This approach to the distal zone of the DFA entails an incision along

Journal of VASCULAR SURGERY

Fig. 5. Posterior approach to the distal DFA. Note fascia] plane and structures separating DFA from superficial femoral vascular structures and isolating it from the subsartorial canal.

the medial border of the sartorius muscle and dissection confined to the plancposterior to the adductor longus (Fig. 5). The posterior approach is applicable when a popliteal or crural bypass must be performed in the presence of an unresolved groin or thigh infection. When the DFA is exposed posteriorly, the adductor longus and its fascial plane isolate the new surgical field from the potentially, or actually, contaminated subsartorial canal. RESULTS The resuks obtained when the distal DFA served as the inflow source for popliteal and crural bypasses are shown in Table II. The only additional complication in this group was a missed arteriovenous fistula in a patient in whom an in situ vein was used. This required ligation under local anesthesia. The results of procedures which involved use of the distal DFA as an outflow tract arc presented in Table III. A superficial thigh wound infection developed in one patient in this group. Another patient had a graft

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infection, which required excision of the graft 12 months after it was placed. DISCUSSION It is current practice to use the CFA for either the origin or termination of bypass grafts of the lower extremity. If significant occlusive disease is present in the CFA or at the origin of the DFA, the proximal DFA is commonly used for arterial reconstruction. When these bypasses fail, limb-threatening ischemia often results. The secondary arterial reconstructions that are required to save the limb can be technically demanding and are more likely to be complicated by wound problems, s The use of the distal DFA, via the direct approaches herein described, avoids the scarred and potentially infected groin and thigh areas. This may facilitate the operation, by allowing the use of a previously undissected artery. By using an inflow site located more distally in the thigh, a shorter segment of graft is necessary. This is particularly important in patients requiring a bypass to the infragenicular popliteal artery or to a crural artery, but in whom available autologous vein length is insufficient because of prior surgery, localized superficial thrombophlebitis, or other reasons. Because autologous vein is widely believed to be the best conduit for such bypasses, the ability to perform the operation with autologous vein may improve long-term patency.6 Furthermore, it has been suggested that when reversed saphenous vein is used as an arterial substitute, patency rates may be higher for shorter length bypasses. 7

The tendency of the DFA to be spared from significant athcrosclerotic occlusive lesions has becn noted. The presence of diabetes plays a decisive role in the distribution of atheroscleroric lesions in the femoral vessels. In nondiabetic patients, severe lc-

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sions will usually be confined to the CFA and SFA, with involvement of the origin of the DFA seen in only 1%. 8 Thus the rest of the DFA is usually disease free. The incidence of severe, synchronous atherosclerotic lesions in both the DFA and the SFA is infrequent, seen in only 7% of patients undergoing arteriography.9 As may be concluded from these observations, most patients who require an inflow procedure for the relief of limb-threatening ischemia have a patent distal DFA, even when the CFA, SFA, and the proximal DFA are occluded. Therefore use of a distal DFA outflow may increase the proportion of patients who can undergo successful arterial reconstruction. REFERENCES 1. Morris GC, Edward WS, Cooley DA, et al. Surgical importance of the prohmda femoris artery. Surgery I961;82:32-7. 2. Martin P, Renwick S, Stephenson C. On the surgery of the profimda femoris artery. Br J Surg I968;55:539-42. 3. DePalma RG, Malgieri Jl~ Rhodes RS, Clowes AW. Profunda femoris bypass for secondary revascularization. Surg Gyn Obstet 1980;151:387-90. 4. Fleming JFR, Levy LF. Lower extremity. In: Grant JCB, ed. An atlas of anatomy. Baltimore: Williams & Wilkins, 1972:257. 5. Flinn WR, Harris JP, Rudo ND, et al. Results of repetitive distal revascularizaton. Surgery 1982;91:566-72. 6. Veith FJ, Gupta SK, Ascer E, et al. Six-year prospective multicenter randomized comparison ofautologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc SuRG 1986;3:104-14. 7. Veith FJ, Ascer E, Gupta SK, et al. Tibiotibial vein bypass grafts: a new operation for limb salvage. J VASC SuRG 1985;2:552-7. 8. King TA, DePalma RG. Diabetes meUitus and atherosclerotic involvement of the profunda femoris artery. Surg Gyn Obstet 1984;159:553-6. 9. Haimovici H. Patterns of arteriosclerotic lesions of the lower extremity. Arch Surg 1967;95:918-33.