Results of endovascular superficial femoral endarterectomy.

BACKGROUND: Endovascular superficial femoral artery (SFA) endarterectomy with a ring stripper/cutter and distal stenting has been suggested to have a patency comparable with above-knee bypass surgery. We report our initial experience with this technique. METHODS: Seventeen patients (13 men and 4 women; mean age, 64 years) with SFA occlusion and above-knee popliteal reconstitution underwent attempted remote endarterectomy with a ring cutter system combined with primary stenting of the distal end point. Analysis was performed in a prospective manner with patency rates determined by Kaplan-Meier life-table analysis. RESULTS: The indication for operation was claudication in 8 patients, rest pain in 6, and tissue loss in 3. Initial technical success was achieved in 11 patients (65%). Reasons for technical failure included SFA perforation (4), inability to traverse a calcified/diseased segment (1), and inability to retract/remove the ring cutter (1). Life-table analysis of all patients revealed a primary patency at 1 year of 26% +/- 11%. Primary-assisted patency was 38% +/- 12% at 1 year, with 59% of patients ultimately requiring surgical bypass grafting. In patients in whom initial technical success was achieved, the 1-year primary and primary-assisted patency rates were 40% and 59%, respectively. There were four reocclusions requiring surgical revascularization with below-knee popliteal (2) or tibial (2) bypass grafting, 1 symptomatic restenosis requiring repeat angioplasty, and 1 symptomatic restenosis treated conservatively. CONCLUSION: The results of endovascular SFA endarterectomy were disappointing, with technical success in less than two thirds of patients and a 1-year primary patency of only 26%. Remote SFA endarterectomy appears less effective than above-knee femoropopliteal bypass grafting, and after early failure, patients may require more distal revascularization for limb salvage.

Early results of infragenicular revascularization based solely on duplex arteriography.

PURPOSE: Recent reports have both advocated and questioned the utility of duplex arteriography (DA) as the sole preoperative imaging modality for planning infragenicular revascularization. This study compares the outcome of patients with critical limb ischemia who underwent infragenicular vein grafts on the basis of DA alone versus conventional preoperative contrast arteriography (CA). METHODS: The study group is composed of 23 consecutive patients who underwent infragenicular vein bypass grafting solely on the basis of preoperative DA from 1998 to 1999. They were compared with 50 consecutive patients who underwent infragenicular vein bypass grafting after CA from 1996 to 1998. Peak systolic velocity and end-diastolic velocity of potential target arteries were recorded during DA studies. In situ saphenous vein grafts were used preferentially, and technical adequacy of all grafts was assessed with completion duplex or arteriography. RESULTS: DA and CA groups were comparable on the basis of age and risk factors. In one limb (4%), the target artery selected by DA was abandoned because of dense calcification. No other revision in target or inflow artery was required on the basis of intraoperative completion studies. At 1 year, primary graft patency (78% vs 70%, P =.72) and limb salvage (70% vs 81%, P =.21) were comparable between the two groups. In the DA group, mean preoperative target artery peak systolic velocity in patent versus failed grafts was 49 +/- 18 cm/s versus 31 +/- 9 cm/s (P =.04), whereas mean end-diastolic velocity was 22 +/- 7 cm/s versus 14 +/- 8 cm/s (P =.08). CONCLUSION: Infragenicular revascularization directed by DA alone provides early graft patency and limb salvage rates comparable to similar procedures that are based on CA. Preoperative DA target artery velocities may predict outcome and improve target selection. These initial results justify further clinical testing of DA as the primary imaging modality for planning infragenicular vein grafts.