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
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.
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.
Advanced imaging methods such as computed tomography (CT) or magnetic resonance angiography (MRA) do not add much to duplex ultrasound as far as defining the presence, nature and severity of CFA and bifurcation pathologies are concerned, though these are helpful in delineating the concomitant proximal and distal steno-occlusive lesions, which in turn guide treatment planning. In critically ischemic legs, the deep femoral artery (DFA) is the only source of limb viability. Hence, visualization of the femoral bifurcation and proximal DFA is critical in management planning. The conventional anteroposterior projection during catheter angiography is inaccurate for adequate visualization of the femoral bifurcation.2 An ipsilateral anterior oblique projection, in addition to the conventional anteroposterior view, significantly improves visualization and accuracy of severity estimation of the femoral bifurcation and ostium of the DFA In an angiographic study reported by McDonald and coworkers, 116 patients were studied with anteroposterior, ipsilateral and contralateral anterior oblique views of femoral bifurcations. Visualization of the femoral bifurcation was improved from 17% to 79% when ipsilateral anterior oblique projections were added to the conventional anteroposterior view (p
Surgical. Focal CFA steno-occlusive lesions are conventionally treated with endarterectomy with or without patch repair. Bifurcation lesions are treated with endarterectomy in conjunction with profundoplasty. Long-term patency rates of common femoral and bifurcation endarterectomy were 95% and 89% at 3 and 5 years, respectively.4 When the DFA is also involved in multilevel disease, adding profundoplasty to inflow bypass surgeries is valuable in improving long-term outcomes. The DFA primarily provides blood supply to the tissues of the thigh, hence, it is critical for maintaining limb viability when the SFA is severely diseased or occluded.
Profundoplasty alone without femoropopliteal reconstruction is useful for ostial deep femoral arterial stenosis and concomitant superficial femoral occlusion presenting with either critical limb ischemia or severe claudication. It is a valuable limb-salvage procedure in patients at high risk for distal bypass.5 When amputation is inevitable, effective perfusion of the profunda femoris artery is essential for stump healing and preservation of the knee joint, and it results in a high degree of functional rehabilitation.6 In a large retrospective series published by Savolainen et al, profundoplasty with patch repair using bovine pericardium resulted in an 80% cumulative clinical success rate; claudicants fared better than those with critical limb ischemia in their report.7 However, surgical treatments involving CFA and bifurcation are mired with prohibitive morbidity rates (21.6%) from wound infections, sutural aneurysms, hematomas, and lymphocele.4
Endovascular. Due to the minimal invasiveness , improving technical success, and mid- and long-term patency rates, endovascular interventions are rapidly substituting the surgical options for vascular diseases of all vascular systems. In addition, endovascular procedures can be used in combination with surgery for multilevel disease such as iliac stenting combined with femoral endarterectomy. The newer endovascular armamentarium such as atherectomy catheters (SilverHawk and RocHawk, ev3, Inc., Plymouth, Minnesota; Diamond back device, Cardiovascular Systems, Inc., St. Paul, Minnesota) further reduced the role of femoral endarterectomy for common femoral artery stenosis.8 These minimally invasive devices are superior to conventional surgery, as they are devoid local wound complications commonly seen following surgical femoral endarterectomy. Plaque debulking with and without adjunctive low-pressure balloon angioplasty is better-suited for arterial segments where stenitng is not favored, as in common femoral and popliteal arterial stenoses. In the largest atherectomy series reported, 250 patients (579 lesions) underwent atheterctomy with/without adjunctive measures involving various infrainguinal arterial segments. The18-month primary and secondary patency rates for claudicants was 58% and 83% (p
To Stent or Not to Stent the CFA?
Controversy shrouds the issue of stenting the CFA, essentially for two presumed reasons:
1) The CFA is located against the hip joint flexion point, which makes the stent vulnerable to strut fracture from repeated hip flexion-extension movements, which in turn may cause in-stent restenosis. This notion might hold true for stiffer balloon-expandable stents, but may not be true for self-expandable nitinol stents. There were no available head-to-head case-control studies comparing angioplasty alone with stenting for CFA as far as long-term restenosis outcomes were concerned. Available data do not categorically support the prevailing perception regarding CFA as a “no-stent zone”.10–13 Stricker et al published their mid-term results involving a series of 27 consecutive patients (33 limbs) with target sites of CFA (n=19), ostial SFA (n=2), DFA (n=4), and bypass graft anastomoses (n=8). The only strut fracture seen was in the patient who had a balloon-expandable stent, while all others with self-expandable stents were fracture-free over a mean follow-up period of 23 months. The 4 cases of restenosis in this study were related to neointimal hyperplasia.10 Neglen and colleagues reported a large case-control study involving 177 limbs with stenting across the inguinal ligament for chronic nonmalignant occlusive iliac venous lesions and compared them with 316 limbs in which the stents were terminated cephalad to the inguinal ligament. Self-expandable, braided stainless steel stents were used in all patients. The cumulative secondary patency rate was 100% for nonthrombotic iliac vein occlusions, regardless of the stent termination in relation to the inguinal ligament, and there were no stent fractures in either group.13
2) Another prevailing notion for stent avoidance in the CFA is that it is the most commonly used access artery for diagnostic and interventional procedures and also a common target artery for supra or inguinal bypass surgeries. Hence, a “stent-jailed” CFA can no longer be used for future access or as a target site if needed. However, the artery can be punctured under fluoroscopic guidance above or below the stent, thus avoiding damage to the stent struts.10
After reviewing the available literature, we recommend CFA stenting, at the discretion of interventionist, for unsatisfactory acute angiographic results following balloon angioplasty to seal blood-flow-limiting dissections, iatrogenic AVF, and perforations, as well as in critical limb ischemia. Preferably usage of shorter (
Deep Femoral Angioplasty
Endarterectomy was considered to be the classic treatment for stenotic lesion involving the DFA and femoral bifurcation. However, with the explosion of endovascular technologies, there have been several reports of successful treatment for deep femoral and bifurcation lesions. The DFA is an important and durable lower-limb outflow artery in patients undergoing revascularization for aortoiliac occlusive disease for critically ischemic limbs.14 Malone and colleagues retrospectively reviewed the natural history of aortofemoral bypass grafts in 180 patients with 360 grafted limbs. With angiographic follow-up, the observed 5-year patency rates were 96% and 75%, respectively, in patients without and with stenoses/occlusion of the femoral bifurcation and DFA, and 0% patency in patients with lesions of both the DFA and the popliteal trifurcation. In patients with known disease of the DFA at the time of surgery, the 5-year patency rate was 95% and 0%, respectively, with and without adjunct profundoplasty.15 These findings underscore the importance of determining the presence of a diseased femoral bifurcation and DFA and treating them in conjuction with supra- or infrainguinal steno-occlusive disease.
Percutaneous angioplasty for the DFA is safe and effective in improving claudication ambulatory distance in patients with concomitant long-segment SFA occlusions.16,17 It is also a limb-salvage option when performed in addition to inflow arterial revascularization procedures for patients with multisegmental disease.8,18,19 Silva et al from the Ochsner clinic reported a series of 31 patients with severe claudication (41%) and critical limb ischemia (59%) secondary to high-grade ostial DFA stenosis, of whom 62% had concomitant SFA occlusion. Excellent techincal success was achieved with angioplasty alone in 90%, with a 94% in-hospital limb salavage rate and a 71% cumulative event-free survival rate at 34 ± 20 months. Additional percutaneous revascularizations of the inflow and/or outflow arteries were required in 69% of study subjects.19
Iatrogenic Common Femoral and Bifurcation Complications
Pseudoaneurysm. The majority of post-catheterization asymptomatic pseudoaneurysms measuring 3 cm size, presence of pain, bleeding, limb ischemia, noncompliance, and sac enlargement at follow-up. Nonsurgical options include ultrasound-guided neck compression or thrombin injection; the former is largely replaced by the later as ultrasound-guided compression is painful, lengthy, and associated with suboptimal closure rates. In a large series involving 306 patients reported by Eisenberg and coworkers, a 75% closure rate was obtained with two attempts, and there were 3 (1%) ruptures.21 Whereas ultrasound-guided thrombin injection is a quick, safe, and effective procedure, in the case-control study by Pezullo et al, ultrasound-guided thrombin injection and compression were associated with 97% and 60% success rates, respectively.22
Arteriovenous fistulae. The incidence of iatrogenic AV fistulae in large series is reported to be 80% of the time with watchful waiting and close follow-up.20 If persistant, the conventional treatment was surgical closure.26 However, safe, effective, and minimally invasive endovascular options include ultrasaound-guided compression, coil embolization of the fistulous communication, and stent-grafting of the CFA across the fistula. Covered-stent placement in the CFA is an effective option for both CFA psueudoaneurysms and AVF. Thalhammer et al reported a series of 29 patients with 16 pseudoaneurysms (9 AVF and 1 combined lesion involving the CFA), and all experienced complications following cardiac catheterization. All patients were treated percutaneously using covered stents with a 90% technical success ate and an 83% 1-year primary patency rate. There were no stent fractures or DFA compromise at follow-up.27
Closure device-related complications. Arteriotomy closure devices such as the Angio-Seal (St. Jude Medical, Inc., St. Paul, Minnesota) can cause acute complications including AVF, pseudoaneurysm, arterial thrombosis, dissection, embolization, and in the long run can present with symptomatic focal CFA stenosis or occlusions in 3% of cases.28 Focal symptomatic steno-occlusive lesions related to arteriotomy closure device usage can be treated with either plaque debulking devices such as the FoxHollow (ev3, Inc., Plymouth, Minnesota), laser atherectomy catheters,29 or plain cutting-balloon angioplasty. Rarely, thrombotic occlusion of the femoral artery presents with acute limb ischemia requiring surgical thrombectomy and arterial repair.
The CFA and its bifurcation are the critical segments of the lower-limb arterial tree. They are rarely involved alone in the atherosclerotic disease process, but are commonly in association with proximal or distal disease. Surgical or endovascular treatment of CFA and DFA stenoses alone or in conjunction with proximal or distal vascular lesions has an important bearing on the clinical improvement and patency outcomes of patients with claudication and critical limb ischemia. Latest technological advances in endovascular medicine offer a promising future in treating iatrogenic and noniantrogenic diseases involving the CVA and its bifurcation.
From the Central Cardiology Medical Clinic and Bakersfield Heart Hospital, Bakersfield, California, and the *Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota.
The authors report no conflicts of interest regarding the content herein.
Address for correspondence: Mallik Thatipelli, MD, RVT, FSVM, FACPh, FACC, Central Cardiology Medical Clinic, 2901 Sillect Avenue, Suite 100, Bakersfield, CA 93308. E-mail: firstname.lastname@example.org