Management of Common Femoral Artery and Bifurcation Diseases
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Introduction and Epidemiology
Isolated atherosclerotic involvement of the common femoral artery (CFA) and its bifurcation are rare and reports consisting large patient series are unavailable. The CFA is usually involved as a continuum with the atherosclerosis of the proximal (iliac) or distal (femoro-popliteal) arterial segments. CFA and its bifurcation are critical segments of the lower-limb arterial tree, exemplified by the development of acute and limb-threatening ischemia when it is occluded with a thrombotic or thrombo-embolic disease process. It is the only inflow artery of the lower limb supplying both the superficial and deep femoral arteries, thus explaining the acuity of clinical presentation when it is occluded. The CFA is the most common access site for all coronary and noncoronary diagnostic and interventional procedures and is also the preferential anastomotic site for supra- or infrainguinal bypass grafting. Hence, the CFA is commonly involved in iatrogenic complications including pseudoaneurysm, arteriovenous fistula (AVF), dissection, sutural aneurysm, infection, hematoma, and lymphocele.30–32
Clinical Presentation
The common femoral and bifurcation steno-occlusive diseases are predominantly atherosclerotic. Patients usually present with life-style-limiting claudication or critical limb ischemia depending on the length of the stenosis, its chronicity, and the presence disease in the adjacent arterial segments. Iatrogenic arterial access complications such as pseudoaneurysm or AV fistula are usually symptomatic with pain, swelling, edema, tenderness, and ecchymosis. Very rarely, the common femoral AVF is large enough to cause hyperdynamic circulation precipitating high-output heart failure. Closure device-related complications can present acutely with symptoms of limb ischemia from femoral artery thrombosis, or chronically, with claudication or rest pain from focal stenosis or occlusion. Acute thrombo-embolism from the left ventricle or proximal aneurysms preferentially lodge at arterial bifurcation points and present with the clinical syndrome of acute limb ischemia; i.e., “pain, pallor, pulselessness, paresthesia, paralysis”. Post-operative complications such as hematoma, cellulitus, and abscess present with fever, erythema, tenderness, and signs of sepsis.
Diagnosis
History and clinical examination and vascular physiology studies such as ankle-brachial indices and Doppler waveforms are usually helpful in identifying and localizing hemodynamically significant stenosis of the common femoral artery and its bifurcation, though advanced vascular imaging studies are usually required to determine the extent and severity of disease and the appropriate patient management strategy. Vascular history includes the nature, severity, and duration of claudication, the presence of rest pain or ulceration, if any, and a detailed description of recent or remote surgical and percutaneous interventions. Patient history about the presence of concomitant cardiovascular risk factors and conditions such as atrial fibrillation, and aortic or iliac arterial aneurysms is helpful. Physical examination includes femoral pulse strength, presence/absence of thrill or bruit, pulsatile masses, groin swelling, and signs of infection or sepsis in cases of suspected infected grafts. A brief cardiovascular examination including heart rhythm, presence of pulsatile abdominal masses, and quality of pedal pulses is also useful.
In the majority of patients with underlying atherosclerotic risk factors the posterior wall of the common femoral artery is commonly involved in atherosclerotic disease, however, the anterior wall is relatively spared due to the differential wall stress along its circumference.1 Due to their anatomical location, the common femoral artery and femoral bifurcation are easily accessible for ultrasound evaluation. Evaluation with color-assisted duplex ultrasound is useful in identifying common vascular pathologies such as groin complications from surgical or interventional procedures, focal common femoral steno-occlusive diseases, their severity, and extent. Ultrasound is also useful during therapeutic interventions such as manual compression or thrombin injection for pseudoaneurysms. It is also an important tool for following percutaneous or surgical interventions of the CFA.
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