remote endarterectomy

Arterial Restoration in CLTI with Remote Endarterectomy (EndoRE).

Posted on June 12, 2019 by docpark

preop PVR

The patient is a man over 70 years of age who came to the hospital with severe pain of his right foot and leg with walking short distances and at night while recumbent. He had a history of hypertension, diabetes, and coronary artery disease, and several years ago had his left common iliac artery stented. On examination, he had no lesions of his foot, and his pulses were only palpable (barely) in the femoral arteries only. He did have strong monophasic signals in the anterior tibial arteries bilaterally.

Initial vascular lab testing showed only mildly depressed ankle brachial (above), with dampened waveforms consistent with inflow and femoropopliteal disease on the right. He underwent arteriography by our vascular medicine specialist and cardiologist Dr. Faisal Hasan, and it showed bilateral common iliac stenoses, a severely calcified and nearly occlusive plaque in the right common femoral artery, and a long segment occlusion in the superficial femoral artery with diffuse calcified plaque extending into the popliteal artery. There was diseased but patent 3 vessel tibial runoff.

aortogram

R SFA arteriogram

To Act As A Unit are the Cleveland Clinic’s words and it shows the Clinic’s roots as an US Army field hospital on the vasty fields of World War I France a little over a century ago, and we take it seriously. It may come as a surprise to some that a cardiologist referred me this patient after mutually deciding that the common femoral disease and the TASC D SFA occlusive disease, but we both decided that a surgical approach was the best one. The question then is how much more flow?

I ordered a CTA (CT angiogram) particularly for endarterectomies as I find it imperative to know the actual end point of plaque. Arteriography only hints at it, and while a 5mm lumen may look large and patent, it may be a channel in a 10mm wide plaque that when a stent terminates within it, breaks and becomes biologically active as intimal hyperplasia at best or embolizes at worst. CTA shown below revealed the plaque where contrast angio showed only the lumena of the vessels.

The 3D reconstruction function also allowed me to see and plan the operative approach and predict the lack of saphenous vein confirmed on duplex ultrasound.

For the students reading this, ischemic rest pain is often simpler to treat because it requires only a little more blood flow. There is a neurologic ischemia component that is not well studied, particularly in diabetics, as ischemia may result in anesthesia in someone who has underlying diabetic neuropathy, but that is not an indication for revascularization while rest pain is, and someone should investigate this. This little more blood flow in the form of treating inflow disease only may be sufficient in relieving rest pain while avoiding interventions on the superficial femoral, popliteal and tibial arteries which have limited longevity.

The common femoral artery on the other hand is the throttle of inflow and as a principle, inflow can be considered as the infrarenal aorta to profunda femoral artery, and repairing the common femoral necessitates an operation. There is no durable or laudable endovascular procedure for occlusive disease of the common femoral artery, a feature shared with the subclavian artery at the thoracic outlet and the celiac axis at the median arcuate ligament. All three are externally compressed by hard structures and revascularization must be ever mindful of the inguinal ligament, the thoracic outlet, and median arcuate ligament. The only exception to the “you must operate” rule of the CFA is calcified atherosclerotic disease in high risk individuals, and I make careful exception here with rotational atherectomy devices.

Claudication is another thing entirely. Claudication limits lifestyle and can be corrected by changing lifestyle -either with more exercise or limiting exercise. The thing is, when a patient has reached a certain age, that lifestyle may be walking slowly from chair to commode, and if that activity is limited, no amount of haranguing may be able to induce that person to embark on an ambitious exercise program. Sometimes, you have to be realistic about telling a frail old man to go for a 60 minute walk. But if that person has difficulty getting to the bathroom because of leg cramps, then either they have to get assistance or more bloodflow, and ironically, a little more blood flow represented by improving inflow, may not be enough.

That was what I was thinking when I was planning this operation. Improve the inflow with stents to the common iliacs and a right CFA endarterectomy, but use the opportunity of surgical exposure to extend the endarterectomy to the distal external iliac and through the entire SFA.

My fondness of remote endarterectomy is well known from my many blog posts on it (link). It is a modern update on a very old procedure -the ring endarterectomy, done since the middle of the last century when bypass grafts were unavailable. The occlusive plaque is removed, and an end-point reached and cut with a scissor like device (available from LeMaitre). It is the ultimate hybrid operation (below) requiring open and endovascular skills. I tell prospective trainees to judge training programs by how facile are the surgeons and how many are the procedures with and involving a hybrid approach, because any program can have few (getting fewer) old surgeons doing only open surgery and a lot of young surgeons doing only endovascular procedures, but a rare few will do a lot of hybrid procedures.

I chose to add femoral EndoRE. This would bring the extra blood flow needed to kickstart any walking program, barring cardiopulmonary limitations.

The patient was brought to our hybrid operating theatre and prepped from nipples to toes. The right common femoral artery was exposed for endarterectomy, and accessed then with a sheath along with a left femoral sheath for kissing balloon angioplasty and stenting of the common iliac artery stenoses (below).

preintervention post kissing stents

Afterword, the CFA was opened and endarterectomized, and the SFA was remote endarterectomized (below).

EndoRE setup EndoRE

The endpoint was chosen in the above knee popliteal artery to avoid having to stent the dissected end point plaque well into the popliteal artery. If I wanted to go all the way to the below knee popliteal artery, I would have to open it to manage the plaque and artery at the so-called trifurcation, typically with a patch angioplasty. The plaque came out in one piece (below):

EndoRE plaque plaque in toto

The terminus of the plaque in the POP where it was cut has to be managed with a stent, unless you open and complete the endarterectomy and patch the artery. I was able to cross the dissection (no small feat) and plaque a stent. The artery was widely patent and even the small branches off the previously occluded SFA were now reopened.

Endpoint management before and after endoRE

His pulse volume recording done after intervention reflects the improved flows (below).

PVR before and after

His rest pain resolved, but more gratifyingly, he has regained the confidence to walk and exercise, which he now does without limitation up to 45 minutes a day. In two month followup, we performed a duplex which showed his right SFA to be basically normal (below), including an intimal stripe and media. This is not an anomaly. When I took a punch out of restored artery to perform an anastomosis (from this case link), I sent it. Previously it had been an artery that was obstructed for nearly a decade, but after EndoRE, had become an elastic, compliant vessel. The pathology returned as “normal artery.”

postop duplex at 2 months

When these fail, they typically do so a random points on the endarterectomized vessel and on the stent. While stent grafting may have better outcomes with regard to restenosis, doing so covers collateral vessels and PTFE grafts behave poorly by embolizing while clotting off, and PTFE stent grafts are no different. Data from over a decade ago suggests that EndoRE of the SFA while inferior in patency to vein grafts, are equivalent to PTFE [reference 1] and superior to endovascular revascularization [reference 2] in terms of primary patency. When they occlude, they achieve a “soft landing” without the furious acute ischemia and embolization seen with PTFE bypasses.

I think these handful of cases I performed here in the UAE represent the first in the region. The main difference here is that the arteries tend to be smaller by about 20%, and in one instance, the smallest Vollmer ring was too large for the vessel in a case where I abandoned the SFA revascularization -the profunda and inflow revascularization proved sufficient in reversing rest pain. The intriguing property of endarterectomy is something that we all try to do with surgery but rarely achieve -a restoration to an earlier time. I believe this patient’s right femoral artery is now back to a youthful state.

References:

Eur J Vasc Endovasc Surg 2009;37: 68-76
J Vasc Surg 2012;56:1598-605.

Arterial Restoration -Something New, Something Old

Posted on September 13, 2017 by docpark

Something that I recently promised Dr. James S.T. Yao, I will be working to publish on my stent removal and extended remote endarterectomy cases and techniques. Meanwhile, here is a talk.

External iliac remote endarterectomy restores the artery to normal, opening the way for EVAR, TAVR, TEVAR, and transplant: alternate applications of EndoRE

Posted on November 18, 2016November 18, 2016 by docpark

preop-cta

One of the nice things about practicing at the Clinic is being able to offer unique solutions. A severely diseased or occluded external iliac artery (EIA) can be a vexing problem, particularly if bilateral, in this endovascular era. Many cardiovascular devices require femoral access that has to traverse compromised iliac arteries -those with large (>16F) delivery systems require a sufficiently wide path to get the devices to the heart and aorta. Also, living related donor kidney transplantation is predicated on minimizing risk to maximize results and having significant iliac plaque negates one as a recipient for this high stakes elective procedure. In situations where the EIA is too small to accommodate devices because of atherosclerotic plaque, the typical solution is placement of a conduit to the common iliac artery or the aorta. The practice of “endopaving” with a covered stent graft and ballooning is also described, but its long term outcomes are not reported and the internal iliac artery is usually sacrificed in this maneuver.

This patient presents with lifestyle limiting claudication and an absent right femoral pulse. ABI is moderately reduced on the right to 0.57, and he had no rest pain. CTA at our clinic revealed an occluded EIA bracketed by severely calcified and nearly occlusive plaque of the common iliac artery (CIA) and common femoral artery (CFA).

The patient was amenable to operation. Traditionally, this would have been treated with some form of bypass -aortofemoral or femorofemoral with a common femoral endarterectomy. While endovascular therapy of the occluded segment is available, one should not expect the patencies to be any better than that of occlusive lesions (CTO’s) in other arteries. Hybrid open/endovascular therapy is an option as well with CFA endarterecotmy and crossing CIA to EIA stents, but I have a better solution.

The common femoral endarterectomy rarely ends at the inguinal ligament, and is uniquely suitable for remote endarterectomy, a procedure from the early to mid twentieth century.

endoRE graphic — Steps in Remote Endarterectomy

The addition of modern fluoroscopic imaging and combining with endovascular techniques makes this a safe and durable operation.

pre intervention.png

The patient was operated on in a hybrid endovascular OR suite. A right groin incision was made to expose the common femoral artery for endarterectomy and left common femoral access was achieved for angiographic access, but also to place a wire across the occlusion into the common femoral artery.

All actions on the external iliac artery plaque are done with an up-and-over wire, allowing for swift action in the instance that arterial perforation or rupture occur. This event is exceedingly rare when the operation is well planned. With this kind of access, an occlusive balloon or repairing stent graft can be rapidly delivered.

The common femoral endarterectomy is done from its distal most point and the Vollmer ring is used to mobilize the plaque. A Moll Ring Cutter (LeMaitre Vascular) is then used to cut the plaque.

Ring dissection.png

The plaque is extracted and re-establishes patency of the EIA.

The plaque end point is typically treated with a stent -in this case, the common iliac plaque was also treated.

What is nice about this approach is that this artery has been restored to nearly its original condition. I have taken biopsies of the artery several months after the procedure in the process of using the artery as inflow for a cross femoral bypass, and the artery clamped and sewed like a normal artery and the pathology returned normal artery.

This has several advantages over conduit creation which can be a morbid and high risk procedure in patients who require minimally invasive approach. A graft is avoided. The artery is over 8mm in diameter where with stenting up to 8mm with an occlusive plaque, the danger of rupture is present, and often ballooning is restricted to 6mm-7mm. This is insufficient for many TEVAR grafts and TAVR valves.

For patients being worked up for living related donor transplants who are turned down because of the presence of aortoiliac plaque, those with the right anatomy can undergo this procedure and potentially become candidates after a period of healing.

Removing Occluded Stents For Critical Limb Ischemia

Posted on April 25, 2015April 25, 2015 by docpark

The patient severe claudication and nocturnal rest pain and had undergone an inflow procedure at another hospital consisting of a common femoral endarterectomy and a single stent to the external iliac artery near its origin from the iliac bifurcation. He also had undergone a concurrent SFA atherectomy which closed and was treated with SFA stents extending from the SFA origin to the above knee popliteal artery. Unfortunately, his rest pain worsened.

On exam, he had a femoral pulse only and no distal pulses, only monophonic and weak pedal signals. The right groin wound had been treated for postoperative wound infection and there was still some swelling and a stitch abscess, but no deep infection. CTA showed that his profunda femoral artery had a focal dissection or stenosis at the origin along with overhang of his SFA stents across the origin of the PFA. The SFA stents were occluded along their whole length. There was remnant disease of the external iliac artery as well.

There was reconstitution of a diseased but patent above knee popliteal artery with three vessel runoff. He had had harvest of his greater saphenous vein. Treatment options included multisegment arm vein with redo profundaplasty, but given the inflammation around his recently operated, recently infected groin, I was concerned for wound infection. He was also quite disabled by his worsened pain. The other option was to access the left common femoral artery and placed a sheath up and over and wire across the diseased profunda and intervene on it, but with the stent in place, I would have to place likely another stent across the origin. I could then attempt a bypass with arm vein or prosthetic graft using this compromised artery as inflow for a bypass to the below knee popliteal artery or a tibial vessel but I doubted this would be durable, nor resistant to infection if prosthetic was used.

Remote endarterectomy (EndoRE) gave me a third option. It is a hybrid technique, but based on an old and established technique of open remote endarterectomy dating from the 60’s. Rings (Vollmer Rings, LeMaitre Vascular) are used to dissect occlusive plaque under fluoroscopy, and a cutting ring (Moll Ring Cutter, LeMaitre Vascular) is used to cut the plaque at the chosen location. Because the distal end point of dissection is not surgically exposed, but rather fluoroscopically guided, it is termed Remote Endarterectomy. Wire skills are required to access and repair any dissections that may occur.

I have presented in the past a series of cases where I removed occluded stents. Because the dissection is carried out outside the plaque, it is also outside the stent. Retrograde EndoRE of SFA plaque can be carried out up to the SFA origin, and avoid a groin incision which in this case was important. Therefore, a proximal thigh exposure of the SFA and EndoRE was planned with endovascular access by left CFA as described.

The SFA was a hard, calcified pipe and control was achieved with vessel loops which allow passage of the ring and occlusion of the artery once the plaque and stents were removed. The artery was opened via longitudinal arrteriotomy and the plaque mobilized and divided. The proximal SFA plaque was then dissected (above and below).

There was immediate establishment of a robust pulse in the proximal SFA after removal of the plaque.

Distally, the plaque would not mobilize at a point in the artery where there was laxity in the artery and especially adherent plaque and therefore, the distal SFA was cut down on to reaccess the stent from below.

Cutdown to reaccess plaque, basically a reversion to the original pre-endovascular technique.

The distal plaque was cut with a Moll Ring Cutter. The removed specimen in total is below.

The arteriotomies were repaired with patch angioplasties using bovine pericardium. This allowed for completing the procedure with endovascular techniques which included the distal end point dissection, profunda stenosis, and external iliac stenosis.

Distal end point managed with self expanding stent.

EIA

At completion, there was a palpable dorsalis pedis artery pulse. The composite angio with preop CTA centerline reconstruction are shown below.

He had relief of his symptoms. Prior to discharge, ABI and PVR’s show normalization of flow to his foot.

Conclusion: In my experience, the longevity of these lesions is dependent on the same factors dictating other revascularizations -excellence of inflow, optimization of profunda outflow, and good tibial outflow. The conduit, being the recanalized original artery, is not as good as a single vein, but it remodels and becomes normal artery based on micro pathology. Failure occurs at the stent with the usual restenosis that can occur in some but not all people, and in isolated points in the artery where likely remnant tissues scar creating focal lesions. Frequent surveillance achieves acceptable primary and secondary patencies. Thromboses do occur. Unlike PTFE grafts, thromboses in EndoRE is usually limited to the recanalized artery without distal embolization. Stent removal is challenging but feasible. In this patient, a second cut down was required to achieve plaque and stent removal. The groin was not re-entered, avoiding dissection in a recently infected, surgical wound. If the popliteal was occluded, a popliteal endarterectomy via a below knee cutdown is possible achieving total femoropopliteal plaque clearance, and the below knee popliteal artery can then be used for a very short bypass to one of the tibial arteries if indicated and if autologous vein is limited in availability.

EndoRE offers a third option after bypass and intervention and should be in a vascular surgeon’s armamentarium.

Saving a patient from hip disarticulation with advanced hybrid inflow procedure and vein bypasses

Posted on April 8, 2015April 8, 2015 by docpark

The patient is an elderly man who had bilateral above knee amputations after failure of aortobifemoral bypass grafts at an outside institution. Unfortunately, he had no femoral pulses and his amputation on the right broke down (image above). His left stump had erosion of his femur to the skin with rest pain as well, but was at least covered by skin for now. He was declared too sick for hip disarticulations and was sent to a hospice where he failed to pass away. After a year there, he was sent to us for an evaluation.

He was suffering from rest pain and had complete breakdown of the skin over his amputation stump. More worrisome was the development of gangrenous scrotal and decubitus ulcers which were small but persistent and also foci of pain. CTA showed the following:

The aorta was occluded below his renal arteries. An AV fistula near his common femoral vein lit up his right iliac vein on the CT above. He had had a prior aortobifemoral bypass but this was occluded. Gratifyingly, it was anastomosed proximally end to side, giving us options. As with any revascularization, we had an inflow source -his aorta, and several potential outflow sources (CTA below, contrast filling iliac vein from AVF’s).

In particular, his distal profunda femoral artery showed promise. Vein mapping revealed a short segment of basilic vein in his arm to use as bypass, but we needed inflow from the aorta.

I have come to appreciate two things about aortoiliac recanalization. First is that passing the wire antegrade is far likelier to stay in the true lumen at least in the aortic inflow segment -retrograde wire passage inevitably dissects the occlusive aortic plaque and reentry into the true lumen of the diseased aorta is just as challenging as in the leg. The second is vein bypasses have excellent patency in challenging conditions -you just need excellent inflow and an arterial bed to perfuse.

My plan was to cross the aortoiliac occlusion with a wire from the left arm. Once the right iliac system was entered, it didn’t matter if I was in a subintimal plane. The wire could be seated in the common femoral artery to access with a surgical exposure. Once this was done, my intention was to perform remote endarterectomy of the external iliac artery and stent from the aorta to the common iliac artery. The endarterectomized external iliac artery would be the inflow source of a later staged ilio-cross femoral bypass to revascularize his left AKA stump. The common femoral artery at its origin would provide inflow to a short vein bypass to his profound femoral artery.

The wire passed readily into the right iliofemoral system and a groin exposure and common femoral arteriotomy allowed me to retrieve the wire which had been passed from the left arm. A remote endarterectomy was performed over the wire which I do to ensure access in case the artery ruptures (specimen below).

This allowed me to place a sheath into the right iliac system in the now reopened external iliac artery. Balloon angioplasty of the aortoiliac segment created working space for placement of balloon expandable stents from the infrarenal aorta to the common iliac artery, restoring an excellent pulse in the right groin.

The profunda femoral artery was encased in scar tissue, but following the occluded PFA from the CFA, I was able to expose an open segment and cut it open in the scar tissue. There was back bleeding, and I controlled the artery by placing a small Argyll shunt into the artery and reperfusing it from the recanalized right iliac system.

The Doppler flow in the shunt was excellent, suggesting great outflow potential. The bypass was performed over the shunt with reversed basilic vein. Completion arteriography showed excellent flow.

The amputation stump was debrided of dead bone and muscle and the graft was covered with a sartorius muscle flap.

Before and after images are shown. The remaining open wound granulated well, and ultimately accepted a split thickness skin graft. His scrotal and decubitus ulcers healed as well (below at 6 months post op).

His left AK stump subsequently degraded while he recovered so three months after this operation, he underwent a right external iliac to left profunda femoral artery bypass with cadaveric vein.

I don’t like using cadaveric vein, but we really had no options. The right external iliac artery was approached through a right lower quadrant (transplant) incision and a punch biopsy of the artery revealed only normal adventitia on pathology. The EIA was soft and sewed well -essentially a normal artery brought back from the dead. The left profound femoral artery was large after endarterctomizing its origin and accepted the bypass flow well.

The mortality from hip disarticulation in the setting of gangrene and infection is very high, and I feel that standard approaches to this problem -prosthetic axillo femoral bypasses, thoracobi-femoral bypasses, in the setting of advanced infection and gangrene were unlikely to succeed. In over 1.5 years of followup, everything has remained patent, and the patient lives independently.

The best last conduit is your own artery

Posted on March 21, 2015March 21, 2015 by docpark

The patient is a 60 year old with severe peripheral vascular disease. Risk factors included smoking, hypertension, and type I diabetes. The patient had developed gangrenous eschar over toes 1, 2, and 3. He had had prior bilateral femoropopliteal bypasses with saphenous vein, which was occluded on his symptomatic side, and stent grafts had been placed on his distal femoral to popliteal artery, but these were occluded. He also had chronic edema with some early lipodermatosclerosis and pitting edema. He was emaciated and had a low prealbumin.

CTA showed diffuse aortoiliac atherosclerosis with a severe stenosis in the proximal common femoral artery.

The femoropopliteal stent grafts were occluded but the popliteal artery reconstituted into a diseased set of tibial vessels -only the posterior tibial artery remained patent into the foot and remained as a target.

Preoperative angiography corroborated the CT findings.

The preoperative vein mapping suggested there was an acceptable anterior thigh tributary vein and marginal segments of vein below the knee. Arm vein was available as well.

My plan was to explore the veins on his legs and expose his CFA and BKPOP along with the posterior tibial artery. If the veins were inadequate, I would proceed with open endarterectomy of the common femoral artery and remote endarterectomy of the external iliac artery and stenting of the diffusely diseased common iliac artery and remote endarterectomy of the femoropopliteal segment above the stent to use as inflow for a shorter bypass with the vein we had.

Exploration showed that the anterior thigh vein was thin walled and became diminutive in the mid thigh. The infrageniculate veins were numerous and too small. I thought I might have enough for a short bypass from a recanalized mid SFA.

The remote endarterectomy of the external iliac and stenting of the common iliac went without complications. I do this over a wire to ensure access in case of rupture. A postop CTA shows the results in the aortoiliac segment.

Remote endarterectomy of the SFA went smoothly but was held up by calcified plaque above the occluded stents.

I cut down on the SFA and found that the vein from the thigh would be short. I mobilized the plaque and re engaged the Vollmer ring and was able to dissect the stents. By starting another dissection from the below knee popliteal artery, the stent was mobilized and removed.

The figure below shows the procedure angiographically. I used a tonsil clamp to remove the mobilized stents.

Left, prior to remote endarterectomy, Mid -stent removal, Right -completion

The common femoral and mid SFA arteriotomies were repaired with patch angioplasties. The infrageniculate popliteal arteriotomy was used as inflow to a very short reversed vein bypass with the best segment of thigh vein to a soft posterior tibial artery.

Before and after, the CTA on right is late in phase and has venous contrast.

The patient had a palpable posterior tibial artery pulse at the ankle. CTA predicted the plaque found in the tibioperoneal trunk which compelled me to do the short bypass. In my experience, remote endarterectomy, sometimes with short single segment bypass, successfully restores native vessel circulation without need for lengthy multisegment arm vein bypass. Remote endarterectomy of the external iliac artery avoids the difficult CFA plaque proximal end point that often requires stenting across the ligament down to the patch. Only a single common iliac stent is required. I generally anticoagulate these patients with warfarin, especially if they are likely to resume smoking or have poor runoff. I hope to show this is the equal of multisegment vein bypass, and superior to it by virtue of avoiding long harvest incisions which are the source of much morbidity and now readmissions which are penalized.

External iliac remote endarterectomy in lieu of a conduit for TEVAR

Posted on February 18, 2015March 25, 2015 by docpark

The patient had diffuse atherosclerosis with small luminal area even in areas without calcified plaque. It predicted inaccessibility for the 22 French sheath required to deliver the 32mm C-TAG device to be placed for a symptomatic type B thoracic aortic dissection associated with a small but expanding proximal aneurysm.

My options included direct aortic puncture, an aortofemoral conduit, or an endoconduit. The aorta was heavily calcified and the bifurcation was narrowed by circumferential plaque down to 6-7mm at its narrowest and the left iliac had a severe narrowing due to this plaque. The common femoral artery was severely diseased with a lumen diameter of 4mm due to heavily calcified plaque.

I have come to favor direct aortic puncture over conduits, but the heavily calcified aorta and the absence of safe areas to clamp made me think about other options. My experience with endoconduits has been limited to revising problems of endoconduits from elsewhere, but others report it as a feasible option.

The problem with a long artery narrowed with irregular plaque and even intimal thickening is that it will readily expand to accommodate a large sheath but removing it involves the frictional resistance of the whole artery and typically the “iliac on a stick” avulsion involves the whole length of external iliac artery, likely because the common iliac is anchored by the aortoiliac plaque, the smaller diameter of the EIA, and the longer more tortuous path offering greater resistance in the EIA compared to the aorto-common iliac segment.

Remote endarterectomy, a technique involving endarterectomizing an artery through a single arteriotomy, offers the possibility of increasing the lumen of even a mildly diseased artery and reducing the frictional coefficient, assuming the remnant smooth adventitia is less resistant than rough irregular intimal plaque.

The plan was to expose the right common femoral artery and endarterectomize it and gain wire access from the R. CFA. A wire would be placed on the left iliofemoral system to protect it for later kissing iliac stents. A right EIA remote endarterectomy would be performed, and then the right aorto-common iliac segment would be balloon dilated to 8mm.

The operation went as planned. The external iliac plaque was removed in a single piece from the EIA origin.

Arteriography showed the right EIA to be free of intimal disease, and dilators and ultimately the 22F sheath went in easily.

The TEVAR also went uneventully -the left subclavian which had a prior common carotid to subclavian bypass, was covered and the aneurysm and flap were excluded from the left CCA to the celiac axis.

The most difficult part of the operation was removing the sheath, as is usually the case with a tight iliac, but the friction point was largely at the common iliac and not the external iliac. No artery could be seen extruding with the sheath at the groin while steady tension was applied to the sheath under fluoro. The aortic bifurcation was repaired with kissing iliac stent. The patient recovered well and her chest pain resolved.

I have done this for EVAR, including reopening occluded external iliac arteries, and even for a 26F access for TAVR, avoiding the need for placement of a conduit in selected patients.

Addendum: in followup, I had the chance to check up on the repair -the EIA remained large and patent.

The EIA is more like SFA than CIA with regard to stent patency

Posted on November 29, 2014 by docpark

From my case files, this was a case which I performed in 2010 and published in a prior blog.

CCx: Patient is a 56 year old man with complaints of pain in right leg with walking short distances and discomfort in the foot at night.

HPI: The patient has had cramps in his right calf with walking about a block for over a year, but over the past three months, he has developed pain with walking less than half a block which is incapacitating. He has developed pain at night which wakes him and he has taken to sleeping with his right foot dangling off the edge of the bed. This has resulted in some swelling of that leg which makes it doubly uncomfortable to wear shoes. He works as a manager at a local big box store and walks constantly. He used to smoke but quit last week. He feels this has worsened the pain.

Past Medical History: Hypertension, dyslipidemia, acid reflux

Past Surgical History: Ruptured appendix at 22

Medications: Zantac, Hydrochlorothiazide, Lipitor, Aspirin

Allergies: Penicillin (rash in 1972)

Social History: Employed, 30 pack year smoking history, quit last week

Examination: T 98 BP 142/88 HR 88 RR 12 Ht 68inch Weight 192lbs

HEENT: PERL, EOMI

Chest: Bilaterally CTA

Cor: RR

ABd: Soft, scar right lower quadrant

Ext: Cool right foot with dependent rubor, elevation pallor. Warm left foot

Neuro: Motor and sensory examination normal

Skin: Loss of hair over toes of right foot, and distal right leg pretibium

Pulses: No palpable pulses right leg. Left leg femoral, popliteal, and dorsalis pedis artery pulses are easily palpable

Labs: WBC 9.8 Hb 13.2 HCT: 40 PLT 332 Cr 0.8

Testing: Segmental pressures R/L: Brachial 144/138 High Thigh 88/150 Low Thigh 77/140 Calf 72/132 Ankle 71/140 Metatarsal 68/122

Pulse volume recordings notable for moderately diminished signals right high thigh cuff.

CTA: Moderate atherosclerosis of infrarenal abdominal aorta and its bifurcation with severe plaque of the right common iliac artery and occlusion of the external iliac artery. There was reconstitution of the common femoral artery on the right via collaterals. The left common iliac artery was affected by a moderate (50-75%) stenosis due to low density plaque.

Impression: PVD with rest pain of right leg due to severe aortoiliac occlusive disease and occlusion of right external iliac artery.

Plan: After discussing treatment options, we decided to try a right external iliac artery remote endarterectomy with angioplasty and stenting of his common iliac disease. This was chosen over aorto-bifemoral bypass because he had limited time off from work and work did require that he lift more than 20 pounds.

Operation:

Remote endarterectomy of right external iliac artery with aortography, bilateral common iliac artery angioplasty and stenting.

This operation was done via a single right groin exposure and percutaneous access of the left groin. The common femoral artery had severe posterior plaque which was the starting point of the endarterectomy. Up and over access of the right external iliac artery was achieved and a wire was passed across the occluded external iliac artery and into the right femoral system. With clamping of the common femoral artery, the wire was brought out and controlled with a Fogarty clamp -this allowed for excellent stabilization and control and possible emergent balloon occlusion in the case of a perforation.

A Vollmer ring dissector was sent over wire and plaque up the external iliac artery under fluoroscopy and dissection was stopped at the iliac bifurcation which was heavily plaqued. A Moll Ring cutting device (LeMaitre) was used to transect the plaque which was removed.

The right and left common iliac arteries were stented with self expanding nitinol covered stents and post-dilated. I chose this as I have had occlusions occur in the setting of diffuse TASC C disease with low density plaque -I suspect that thrombus propogates across open cells like weeds growing through chicken wire. The stents on the right were extended across the iliac bifurcation.

A completion angiogram is here to the right. The common femoral artery was repaired with a patch angioplasty (bovine pericardial patch, LeMaitre).

The groin was closed and the patient recovered and was discharged in a few days with excellent palpable pulses on the right and improved pulses on the left. He was without symptoms of claudication or rest pain in the right leg.

Discussion:

Remote endarterectomy allows for removal of plaque via a single groin incision, obviating the need for an abdominal exposure required in an aorto-bifemoral bypass. This minimally invasive technique is associated with a low complication rate and earlier return to full work status because the abdominal incision is avoided.

Smeets et al [reference] reviewed with 7 year experience with 48 patients and had a technical success rate of 88%. One patient died due to a myocardial infarction within 30 days of the operation. The complication rate was low. 6 patients required coversion (retroperitoneal flank exposure) for additional arteriotomy (3 patients) and bypass (3 patients). The primary and assisted patencies shown to the right were acceptable with a secondary patency of 94% at 3 years.

These cases require more surveillance than an aortobifemoral bypass. Intimal hyperplasia does occur in random loci in the SFA remote endarterectomy and this should apply to the external iliac artery. I chose the title because the external iliac artery biologically behaves like the superficial femoral artery in relation to endovascular patencies and not like the common iliac artery or aorta -probably because it shares a common embryology with the SFA, not the CIA. It is a troublesome artery that is often overlooked by vascular surgeons when femorofemoral bypass is performed for occlusive disease -the supplying external iliac artery though patent is usually diseased and has a small lumen. With a fem-fem bypass, both legs are supplied often through an artery with the caliber of a child’s drink straw. I have seen the donor leg become symptomatic through what is termed steal, but in fact reflects the hemodynamic inadequacies of a diseased external iliac artery.

I feel that 5mm is the minimal lumen caliber for an external iliac artery, and a 4mm lumen in an adult will clearly show a hemodynamic effect particularly after exercise or application of vasodilators in the endo suite. Stenting an occluded external iliac artery though technically feasible even in this case is not a durable solution in my experience. This operation allowed the patient to return to work without an extended convalescence.

I think removing the plaque offers advantages over stenting to the inguinal ligament. The common iliac stents have superior potency to external iliac artery stents and moving the stent point to the CIA and not stenting the EIA in my experience has better long term potency.

Reference

Smeets L, et al. J Vasc Surg 2003;38:1297-1304.

Tibial Endarterectomy in Conjunction with Popliteal Endarterectomy in Lieu of Bypass

Posted on November 24, 2014November 24, 2014 by docpark

The patient is an elderly woman who had severe rest pain due to popliteal artery and tibial occlusion. She had no leg veins and sparse arm veins which would have to be spliced to achieve a femoro-peroneal bypass. Her preop CTA showed a patent SFA and proximal popliteal artery occluding above the joint and reconstituting only the peroneal artery. I planned for a retrograde popliteal remote endarterectomy tibioperoneal trunk endarterectomy via a below knee exposure with patch angioplasty of the arteriotomy, the bailout would be a short arm vein bypass from the above knee popliteal artery to peroneal artery.

Arteriography was performed via a left common femoral access and is shown below.

The popliteal artery was occluded and there was a very small peroneal artery that continued down the leg with seeming occlusion of the anterior and posterior tibial arteries. The popliteal and anterior tibial artery were exposed through a below knee incision taking care to avoid venous injury which can be troublesome source of bleeding. The tibioperoneal trunk down to the bifurcation and origin of the peroneal artery was exposed through the same incision. And anterior tibial artery origin was controlled with a vessel loop largely out of habit although it seemed clear it was occluded, as were the proximal popliteal and tibioperoneal trunk branches. The arteriotomy was created from the tibioperoneal trunk to the popliteal artery and endarterectomy was performed from distal to proximal to create a starting point for the ring dissectors used in remote endarterectomy. The anterior tibial plaque branched off much like an external carotid artery plaque and I decided to see what would happen if I did an eversion endarterectomy. I was able to mobilize a short length of the artery and was able to pull as I endarterectomized around the plaque and it thinned very nicely and came out with a gossamer end point. More gratifyingly, the backbleeding was excellent –this was controlled with the vessel loop very nicely. The retrograde popliteal endarterectomy was performed as described in another post in another case –link. The artery was then patched and completion arteriography was performed.

What was fascinating was it seemed I had reopened not just the pop-peroneal axis but the anterior tibial artery was also open, very dramatically so. The patient also had a bounding dorsalis pedis artery pulse. She recovered and went home two days later and in three years of followup while I was still in Iowa, she remained widely patent, maintained on Coumadin anticoagulation.

Popliteal endarterectomy for localized popliteal artery disease has been described (reference) with decent short term patency and successful limb salvage. Nasr et al. performed their endarterectomy via a posterior exposure. I think I recall coming across this in a book chapter from the old Wylie textbook which is long out of print. I think that the anterior tibial artery never lit up well because it was part of a highly developed collateral network, but it was patent all along. Duplex which was not done, would have given a better indication of its patency. I think that the patency of the popliteal endarterectomy is related to its relative shortness and in this case, the added outflow cannot hurt.

Reference

Nasr H et al. Popliteal endarterectomy for localized popliteal artery disease. Ann Vasc Surg 2014 (in press).

Popliteal Endarterectomy and Short Bypass in Lieu of Multisegment Vein Bypass

Posted on November 12, 2014November 12, 2014 by docpark

The patient is a very pleasant elderly lady who had a prior EVAR complicated by graft limb thrombosis treated with thrombectomy. She recovered from that but subsequently developed ulceration of her left ankle. She had been sleeping in a chair because it hurt her to sleep flat –her leg and foot would burn with pain. A wound care center had tried an Unna’s boot, but it caused her worse pain, and the ulcer increased in size. At admission, she had an exquisitely tender, edematous leg and ankle with a large ulcer weeping edema fluid. There were no palpable pedal level pulses.

I admitted her for workup and treatment of a mixed etiology arterial and venous ulcer.

These are patients for whom rest pain is relieved by avoiding recumbency, but with prolonged sitting, as in this lady, edema accumulates and starts to leak, creating an ulcer of the venous type, in the medial ankle (gaiter) region. These don’t resolve without addressing the underlying cause which is the arterial insufficiency. Fixing the arterial insufficiency then allows for leg elevation and compression. For the trainees, venous ulcers almost uniformly heal with Unna’s boot therapy. Elevation should relieve discomfort in venous ulcers. Neither of these occurred and raises the suspicion of arterial insufficiency.

At admission, her PVR’s showed severe popliteal/tibial level occlusive disease. CTA was performed and it showed the common femoral and superficial femoral arteries to be patent but plaque occluded the popliteal artery and origins of the tibial vessels.

The only patent runoff was via her peroneal artery. Centerline evaluation of the CT scan was performed, with manual centerline created through the occluded segment of popliteal artery. I find this useful for planning endarterectomy and bypasses, and with attention to detail, images that are the equivalent to tibial angiograms come to life. This is a centerline through the femoropopliteal to peroneal system.

Vein mapping revealed a paucity of good vein –only a short segment in the proximal thigh on the left and for a short segment on the right. Stress testing revealed that she was good to moderate risk. Isolated popliteal occlusive disease with poor tibial runoff, while feasible for intervention, is not likely to be durable. Multisegment vein bypass on the other hand, using at least three segments, meant a long operation for this frail old lady and a prolonged recovery. I felt that popliteal endarterectomy and distal SFA remote endarterectomy offered a good option for revascularization, with either a patch repair or a short bypass to the peroneal artery. The backup plan was composite vein, but it was unlikely to be needed because the plaque was not the calcium pipe type plaque that does not endarterectomize well.

The patient was positioned on the table supine. The short segment of proximal greater saphenous vein was harvested –it was of suitable caliber, but below its first major tributary point, the veins was thick walled and small. The total length was about 10 cm. The below knee popliteal space was opened and the popliteal through tibioperoneal trunk bifurcation was exposed. Antegrade puncture of the common femoral artery allowed for arteriography and it showed the occlusion at the knee with reconstitution of the peroneal artery.

The popliteal artery was opened and endarterectomy of the occlusive plaque was performed. Retrograde remote endarterectomy (EndoRE) with Vollmer rings was performed to the mid superficial femoral artery where on the CTA the calcified plaque ended. The technical point about retrograde EndoRE is that the ring catches as the plaque gets larger more proximally, and has to be swapped out for a larger ring. Ultimately a 7mm Moll Ring Cutter was used to cut the plaque (picture below, arrow to more proximal SFA plaque).

The plaque, because it is larger the more proximal you go, came out with some difficulty via the below knee popliteal artery. This is not a great concern if it won’t come out –you merely have to cut down on the SFA in the thigh to fish out the plaque. In this case, it was not necessary, and it came out in several pieces, facilitated by the cutter which was used to graft the plaque in segments to retrieve it. Unfortunately, I don’t have a picture from this case of the plaque, but I have inserted a popliteal endarterectomy plaque image below from an prior case of popliteal endarterectomy.

This restored pulsatile flow to the below knee popliteal artery. Opening the artery down to the tibioperoneal artery revealed the artery to occluded and I took the endarterectomy to the peroneal artery origin and everted a short segment of posterior tibial plaque. The peroneal artery was large and would accept flow readily, so I chose to bypass to it using the short segment of saphenous vein that I had harvested for a possible patch or short bypass. The vein was reversed and anastomosed in the usual manner. Arteriograms are below.

The flows were multiphasic. I attempted to cross the posterior tibial occlusion but ended up with contrast extravasation, therefore stopped with this repair. The patient’s wounds were closed and ulcer cleansed and compressed. In the week postop, she healed her ulcer and her two short incisions, and felt good enough to go home with homecare. Her noninvasive studies and duplex confirmed the patency of her revascularization, and there was a multiphasic signal in her posterior tibial artery as well as peroneal.

In the handful of patients I have managed this way, either with popliteal endarterectomy and patch or short (micro) bypass, they have stayed patent past a year, but do require surveillance. Because of her frailty and unsteadiness of gait, I chose not to anticoagulate with Coumadin which is my usual practice, but have her on Plavix and aspirin.

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