Back to Karmody Posters

OBJECTIVES: Remote Endarterectomy (RE) is a hybrid procedure conceived as an alternative to a bypass constructed with less than ideal conduit. We present a case series of modified RE enhanced by the addition of a distal leg incision to complete the endarterectomy utilizing a “flossing” technique that permits long segment plaque excision.
METHODS: A retrospective chart review identified RE procedures performed from May 2010 through March 2012. All patients had a prior failed subintimal angioplasty attempt for Rutherford class 3-5 ischemic indications. The technique involved femoral artery exposure, plus a distal incision exposing the popliteal artery either above or below the knee. The Vollmar ring dissector was utilized to extract plaque from the femoropopliteal arterial segment via each arteriotomy. Adjunctive patch angioplasty was used to close the arteriotomies. Demographics, lesion characteristics, procedural details and outcome data were collected. Study endpoints were death, occlusion, reoperation, or last office follow-up visit.
RESULTS: RE was performed in 11 patients (5 men; mean age of 68 years, 3 diabetics, 11 tobacco users). Indication for operation was severe claudication in 6, rest pain in 3 and gangrene in 2. RE was technically successful in all patients. Distal arterial exposure was above knee in 7 (64%), below knee in 2 (18%), and combined above and below knee exposures in 2 (18%) patients. Two patients underwent concomitant balloon angioplasty in either the popliteal or anterior tibial vessels. Mean post-operative ABI increase was .43 (P=.001). Operative complication of above knee popliteal artery perforation occurred in 1 patient, but was successfully repaired with covered stent deployment. Average procedure duration was 162 minutes ± 69 minutes (SD) and average hospital stay was 4 days. All patients reported rest pain resolution; both patients with tissue ulceration healed. During the twelve month follow up time period, a femoropopliteal re-occlusion developed in 4 patients resulting in 1 patient who will require bypass, which is pending. Limb salvage rate was 100%.
CONCLUSIONS: When endovascular therapies are exhausted, and should autologous saphenous vein be unavailable, the dual incision RE technique of long segment femoropopliteal occlusive lesions accomplishes effective revascularization. Limb salvage was achieved in all patients; the need for a subsequent bypass was rare and not adversely affected by having undergone the dual incision RE.