Management of Common Femoral Artery and Bifurcation Diseases
- Volume 7 - Issue 1 - January 2010
- Posted on: 1/7/10
- 0 Comments
- 18511 reads
Mallik Thatipelli, MD, RVT, FSVM, FACPh, FACC and Sanjay Misra, MD*
pg. E27 - E30
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.
1. Kornet L, Hoeks AP, Lambregts J, Reneman RS. In the femoral artery bifurcation, differences in mean wall shear stress within subjects are associated with different intima-media thicknesses. Arterioscler Thromb Vasc Biol 1999;19:2933–2939.
2. Beales JSM, Adcock FA, Frawley JS, et al. The radiological assessment of disease of the profunda femoris artery. Br J Radiol 1971;44:854-859.
3. McDonald EJ Jr, Malone JM, Eisenberg RL, Mani RL. Arteriographic evaluation of the femoral bifurcation value of the ipsilateral anterior oblique projection. Am J Roentgenol 1976;127:955–956.
4. Cardon A, Aillet S, Jarno P, et al. Endarteriectomy of the femoral tripod: Long-term results and analysis of failure factors. Ann Chir 2001;126:777–782.
5. Rollins DL, Towne JB, Bernhard VM, Baum PL. Isolated profundaplasty for limb salvage. J Vasc Surg 1985;2:585–590.
6. Manouguian S.Revascularization of the profunda femoris artery in ischemia of the stump after above knee amputation. Zentralbl Chir 2001;126:157–160.
7. Savolainen H, Hansen A, Diehm N, et al. Small is beautiful: Why profundaplasty should not be forgotten. World J Surg 2007;31:2058–2061.
8. Dieter RS, Pacanowski JR Jr, Ahmed MH, Mannebach P, Nanjundappa A. FoxHollow atherectomy as a treatment modality for common femoral artery occlusion. WMJ 2007;106:90–91.
9. McKinsey JF, Goldstein L, Khan HU, et al. Novel treatment of patients with lower extremity ischemia: Use of percutaneous atherectomy in 579 lesions. Ann Surg 2008;248:519–528.
10. Stricker H, Jacomella V. Stent-assisted angioplasty at the level of the common femoral artery bifurcation: Midterm outcomes. J Endovasc Ther 2004;11:281–286.
11. Silva JA, White CJ, Quintana H, et al. Percutaneous revascularization of the common femoral artery for limb ischemia. Catheter Cardiovasc Interv 2004;62:230–233.
12. Zollikofer CL, Schoch E, Stuckmann G, et al. Percutaneous transluminal treatment of stenoses and obstructions in the venous system using vascular endoprostheses (stents). Schweiz Med Wochenschr 1994;124:995–1009.
13. Neglén P, Tackett TP Jr, Raju S. Venous stenting across the inguinal ligament. J Vasc Surg 2008;48:1255–1261. Epub 2008 Sep 4.
14. Prendiville EJ, Burke PE, Colgan MP, et al. The profunda femoris: A durable outflow vessel in aortofemoral surgery. J Vasc Surg 1992;16:23–29.
15. Malone JM, Moore WS, Goldstone J. The natural history of bilateral aortofemoral bypass grafts for ischemia of the lower extremities. Arch Surg 1975;110:1300–1306.
16. Bulvas M, Chochola M, Herdová J, Urbanová R. Percutaneous transluminal angioplasty of the deep femoral artery. Cor Vasa 1993;35:183–187.
17. Müller-Bühl U, Strecker EP, Göttmann D, et al. Improvement in claudication after angioplasty of distal ostial collateral stenosis in patients with long-segment occlusion of the femoral artery. Cardiovasc Intervent Radiol 2000;23:447–451.
18. Ol’Shanski MS, Esipenko VV, Ivanov AA, et al. Endovascular correction of a multi-level arterial lesion in an elderly patient with lower-limb critical ischaemia. Angiol Sosud Khir 2007;13:42–44.
19. Silva JA, White CJ, Ramee SR, et al. Percutaneous profundaplasty in the treatment of lower extremity ischemia: Results of long-term surveillance. J Endovasc Ther 2001;8:75–82.
20. Toursarkissian B, Allen BT, Petrinec D, et al. Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae. J Vasc Surg 1997;25:803–808; discussion 808–809.
21. Eisenberg L, Paulson EK, Kliewer MA, et al. Sonographically guided compression repair of pseudoaneurysms: Further experience from a single institution. Am J Roentgenol 1999;173:1567–1573.
22. Pezzullo JA, Dupuy DE, Cronan JJ. Percutaneous injection of thrombin for the treatment of pseudoaneurysms after catheterization: An alternative to sonographically guided compression. Am J Roentgenol 2000;175:1035–1040.
23. Muller DW, Shamir KJ, Ellis SG, Topol EJ. Peripheral vascular complications after conventional and complex percutaneous coronary interventional procedures. Am J Cardiol 1992;69:63–68.
24. Oweida SW, Roubin GS, Smith RB 3rd, Salam AA. Postcatheterization vascular complications associated with percutaneous transluminal coronary angioplasty. J Vasc Surg 1990;12:310–315.
25. Kim D, Orron DE, Skillman JJ, et al. Role of superficial femoral artery puncture in the development of pseudoaneurysm and arteriovenous fistula complicating percutaneous transfemoral cardiac catheterization. Cathet Cardiovasc Diagn 1992;25:91–97.
26. Cohen JR, Sardari F, Glener L, et al. Complications of diagnostic cardiac catheterization requiring surgical intervention. Am J Cardiol 1991;67:787–788.
27. Thalhammer C, Kirchherr AS, Uhlich F, et al. Postcatheterization pseudoaneurysms and arteriovenous fistulas: Repair with percutaneous implantation of endovascular covered stents. Radiology 2000;214:127–131.
28. Kirchhof C, Schickel S, Schmidt-Lucke C, Schmidt-Lucke JA. Local vascular complications after use of the hemostatic puncture closure device Angio-Seal. Vasa 2002;31:101–106.
29. Steinkamp HJ, Werk M, Beck A, et al. Excimer laser-assisted recanalisation of femoral arterial stenosis or occlusion caused by the use of Angio-Seal. Eur Radiol 2001;11:1364–1370.
30. Wyman RM, Safian RD, Portway V, et al. Current complications of diagnostic and therapeutic cardiac catheterization. J Am Coll Cardiol 1988;12:1400–1406.
31. Bourassa MG, Noble J. Complication rate of coronary arteriography. A review of 5250 cases studied by a percutaneous femoral technique. Circulation 1976;53:106–114.
32. Kelm M, Perings SM, Jax T, et al. Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: Implications for risk stratification and treatment. J Am Coll Cardiol 2002;40:291–297.