Hayes Daniel J, Dougherty Matthew J, Calligaro Keith D
Vascular and Endovascular Therapy, Pennsylvania Hospital, Philadelphia, PA, USA.
Ann Vasc Surg. 2011 May;25(4):559.e19-23. doi: 10.1016/j.avsg.2011.02.004.
Flush occlusions of the superficial femoral artery (SFA) often preclude endovascular interventions for femoral-popliteal lesions. Furthermore, some investigators have found poor results with angioplasty and stenting or stent-grafting of such lesions. For suitable patients with TransAtlantic Inter-Society Consensus (TASC) C and D femoral-popliteal lesions involving a flush occlusion of the SFA, we have adopted a technique to manage this disease pattern by combining femoral endarterectomy through a single, small groin incision with distal superficial femoral-popliteal stent-grafting. In this article we have described our technique and results in 14 consecutive patients.
A total of 14 patients who underwent this hybrid procedure between May 2005 and April 2009 were identified from our prospectively gathered registry. Data on indications, complications, length of hospital stay, pre- and postoperative ankle-brachial indices, patency determined by duplex ultrasonography, limb salvage rates, and functional results were collected.
Of the 14 patients, nine were operated on for disabling claudication, two for rest pain, and three for tissue loss; three fit TASC C criteria and the remaining 11 fit TASC D. In all, 12 patients had stent-grafts placed and two had bare-metal stents inserted. The median ankle-brachial index of the affected leg was 0.61 (range, 0.23-1.71) before surgery and 0.99 (range, 0.63-1.39) after surgery (p = 0.034). There were no significant complications associated with the procedure. One patient died secondary to unrelated causes 5 months later, two did not return for follow-up after discharge, and three were lost to follow-up after primary patency was confirmed at 2, 4, and 4 months, respectively. Of the remaining eight patients, four still have primary patency of their stent-grafts at 52, 19, 17, and 4 months, respectively, and a fifth patient has secondary patency at 24 months. The remaining three patients occluded their stent-grafts with primary patency last confirmed at 0.5, 2.5, and 8 months, respectively; two have stable claudication and one has a nonhealing wound and rest pain, but all have limb salvage to date.
Combined femoral endarterectomy and endovascular femoral-popliteal stent-grafting provides a viable option for revascularization of flush SFA occlusions with only a minimal groin incision. The technique described in this article allows for a larger number of patients with flush SFA occlusions to be treated primarily with endovascular techniques and helps avoid a traditional common femoral to above-the-knee popliteal prosthetic bypass.
股浅动脉（SFA）的平齐闭塞常常使股腘病变的血管内介入治疗无法进行。此外，一些研究者发现对此类病变进行血管成形术、支架置入术或支架移植物置入术的效果不佳。对于患有跨大西洋两岸血管外科学会共识（TASC）C 型和 D 型股腘病变且涉及 SFA 平齐闭塞的合适患者，我们采用了一种技术来处理这种疾病模式，即通过单一小腹股沟切口进行股动脉内膜切除术并联合远端股浅 - 腘动脉支架移植物置入术。在本文中，我们描述了我们对 14 例连续患者采用的技术及结果。
从我们前瞻性收集的登记册中确定了 2005 年 5 月至 2009 年 4 月期间接受这种联合手术的 14 例患者。收集了关于适应证、并发症、住院时间、术前和术后踝肱指数、通过双功超声确定的通畅率、肢体挽救率以及功能结果的数据。
14 例患者中，9 例因致残性间歇性跛行接受手术，2 例因静息痛接受手术，3 例因组织缺损接受手术；3 例符合 TASC C 标准，其余 11 例符合 TASC D 标准。总共 12 例患者置入了支架移植物，2 例插入了裸金属支架。患侧术前踝肱指数中位数为 0.61（范围 0.23 - 1.71），术后为 0.99（范围 0.63 - 1.39）（p = 0.034）。该手术未出现重大并发症。1 例患者 5 个月后因无关原因死亡，2 例出院后未返回进行随访，3 例分别在术后 2 个月、4个月和 4 个月确认初次通畅后失访。其余 8 例患者中，4 例分别在 52 个月、19 个月、17 个月和 4 个月时其支架移植物仍保持初次通畅，第 5 例患者在 24 个月时实现了二次通畅。其余 3 例患者的支架移植物闭塞，初次通畅分别在 0.5 个月、2.5 个月和 8 个月时得到确认；2 例有稳定的间歇性跛行，1 例有不愈合伤口和静息痛，但目前所有患者的肢体均得以挽救。
联合股动脉内膜切除术和血管内股腘动脉支架移植物置入术为平齐 SFA 闭塞的血管重建提供了一种可行的选择，只需一个极小的腹股沟切口。本文所述技术使更多平齐 SFA 闭塞患者能够主要通过血管内技术进行治疗，并有助于避免传统的从股总动脉到膝上腘动脉的人工血管旁路移植术。
