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Objective: To review outcomes of remote iliofemoral endarterectomy (RIE) using Vollmar Ring Dissectors (LeMaitre Vascular, Burlington, MA) for the novel hybrid treatment of iliofemoral arterial occlusive disease.
Methods: Retrospective review identified 8 patients who underwent RIE between December 2006 and March 2011. Mean patient age was 65.6 years. The 8 patients underwent a total of 9 procedures performed by a single surgeon. Four patients presented with lifestyle-limiting claudication, 4 with rest pain, and one with gangrene.
Open femoral exploration allowed longitudinal arteriotomy for lumenal access and development of an endarterectomy plane. A Vollmar Ring Dissector was passed superiorly from this plane in the femoral artery until the offending plaque fractured proximally. The Vollmar Dissectors ranged from 5-10 mm. Adjunctive angiography was performed in 8 cases (89%). Four cases required stents.
Results: Inflow was restored in 8 cases (89%). In 3 cases (33%), palpable pedal pulses were attained. In 5 cases (56%), augmented distal Doppler signals were realized. In one case, RIE was not successful, and a femoral crossover bypass was necessary. Two cases resulted in proximal dissection of the occluded vessel, likely secondary to incomplete endarterectomy. Iliac inflow was re-established by placing a stent above “no man’s land” in the proximal external iliac artery. In 2 cases, endarterectomized plaques fractured at 6 cm and 7 cm above the inguinal ligament; however, complete plaque extraction was achieved without additional intervention. There were no post-operative morbidities or mortalities. On average, patients were discharged on post-operative day 4.6.
Study endpoints included an initial post-operative visit at 1-3 months and a follow-up visit a minimum of 2 months later. Outcome measurements included: lifestyle-limiting claudication and rest pain, distal pulse exam, ABIs, and distal Doppler signals. At the initial follow-up visit, 7 cases (88%) showed improvement in symptoms. At the second follow-up, 5 (71%) maintained improvement.
Conclusions: RIE utilizing Vollmar Ring Dissectors integrates open and endovascular techniques to avoid stent placement at the level of the inguinal ligament - a “no man’s land,” inhospitable to stenting. This novel hybrid technique opens new avenues in the treatment of iliofemoral arterial occlusive disease.