CC BY
12
UDC 616.137.83-089
SIDE ANGIOPLASTY OF SUPERFICIAL FEMORAL ARTERY
1 Altai State Medical University, Barnaul
2 Multiprofile hospital of JSC Russian Railways at the Barnaul station, Barnaul N.G. Khorev12, A.V. Beller2, V.O. Kon'kova1, Yu.G. Belokrylova1, Ya.N. Shoikhet1
There is presented the surgical technique of the side superficial femoral artery angioplasty. Early results of operations are presented in two groups of patients. Group 1 - endovascular surgery (45 patients), group 2 -lateral angioplasty group (44 patients). Statistically significant differences in the outcomes of these interventions nearby were observed. Side angioplasty may be considered as an alternative to endovascular interventions. Key words: endarterectomy, superficial femoral artery, popliteal artery, angioplasty.
Currently, from 8 to 12 million US residents have peripheral arterial disease [1]. Over the past 10 years, the US has seen a paradigm shift from open surgery to endovascular therapy. The number of endovascular procedures by critical ischemia increased by four times and twice by intermittent claudication. This led to a decrease in the number of large amputations, a reduction in hospital stay [2]. However, endovascular treatment faces serious limitations. The procedure of endovascular angioplasty in the presence of chronic total occlusion is complicated by dissection, perforation and distal embolism. Stents used to prevent these complications cannot withstand significant biomechanical loads, including compression, flexion, stretching and torsion, especially in the knee joint area. This leads to destruction (fracture), stenosis and occlusion of the stent [3]. It is possible to avoid these complications with the use of endarterectomy technology, which makes it possible to reduce the volume of atherosclerotic plaque with minimal changes inside the vessel [4, 5]. However, the devices and expendable materials for this technology (SilverHawk, ROTAREX, Diamondback 360 °) are of high cost, and the process of arterectomy is poorly controlled due to the lack of direct visual control. Therefore, the improvement of the method of atherectomy-endarterecto-
my (EAE) using an open surgical approach seems to be quite promising.
Materials and methods
To improve the method of endarterectomy, we proposed an operation of lateral angioplasty of the superficial femoral artery (Figure 1). For the planning of this operation at the pre-hospital stage, duplex scanning and MSCT angiography are performed. In the hospital, the nature of the lesion is determined with the use of conventional angiogra-phy, according to the results of which the condition of the superficial femoral artery (SFA) and proximal popliteal artery (PPA) is improved above and below the lesion zone in which the EAE is supposed to be performed. Indications for surgery were short segmental occlusions or stenoses of the distal segment of SFA and the initial section of PPA - zone of maximum deformations of the vessels (Fig. 2). The study included 89 patients, which were divided into two groups, depending on the type of operation performed. The first group consisted of 45 patients who underwent endovascular treatment; the second group - 44 patients. These patients underwent lateral angioplasty. The study groups of patients are comparable in the main clinical features (Table 1).
Clinical feature 1 group - endovascular operation (n=45) 2 group - side angioplasty (n=44) P
Age (years) 48 - 73 49 - 69 > 0,05
Gender:
male 31 33 > 0,05
female 14 11 > 0,05
Degree of ischemia: IIB - III (A.V. Pokrovsky), 3.4 category (Rutherford) 45 44 > 0,05
Extent of stenosis or occlusion 3 - 12 5 - 13 > 0,05
(cm)
SFA occlusion 19 27 > 0,05
SFA stenosis (70 - 95%) 26 17 > 0,05
Table 1
Characteristics of patients with atherosclerotic lesions of the superficial femoral artery
Results and discussion
A comparative evaluation of early complications (up to 30 days) in two groups of patients is presented in Table 2. It should be noted that there was no statistically significant difference in early failures of both types of revascularization. All complications were eliminated and blood flow res-
toration was performed using a bypass operation. At the same time, there is a tendency for the growth of immediate failures in endovascular procedures. The most significant complication is the breakdown of the stent, established during the endovas-cular operation (Figure 3).
Table 2
Early complications of surgical treatment of short distal lesions of the superficial femoral and popliteal arteries
Operation type Complications of early postoperative period Number of complications Abs. (%) Method of elimination of complications p
Side angioplasty (n=44) SFA trombosis 1(2,3%) FPS above the knee by autovein >0,05
Endovascular angioplasty (n=45) - Technical failure - Stent failure and early thrombosis 2 (4,4%) FPS above the knee by autovein
Note: SFA - superficial femoral artery; FPS - femoral-popliteal shunting
Currently, a variety of technical solutions are used to revascularize the femoral-popliteal artery arteries. This is balloon angioplasty, which has recently been replaced by more effective approaches [6]. Uncovered metal stents poorly adapt in the vascular bed [7]. The use of coated stents made it possible to reduce the number of resteno-ses [8,9]. The greatest interest at present is focused on the use of stents [10] and balloons [11] with drug coating.
Despite these technological advances, endarter-ectomy from SFA and PPA remains in the arsenal of open vascular surgeries [12]. In 2012, a group of Italian surgeons Gabrielli R, et al [13] demonstrated the advantage of endarterectomy before en-dovascular procedures by the defeat of TASC-II D [14] in the criteria of patency, including in patients with "critical ischemia." In our study, an open end-arterectomy is proposed that combines the benefits of visual control of completeness of operation and atherectomy, which preserves the biomechan-ical properties of distal SFA and PPA. The immediate results of this operation are comparable with endovascular procedures. Thus, lateral angioplasty of the SFA in the zone of the leading canal (area of pronounced load) allows performing surgical remodeling of the artery, qualitatively more approximate in biomechanical characteristics to the natural wall of the vessel.
Conclusions
1. The operation of the lateral angioplasty can be considered as an alternative to endovascular interventions in the treatment of segmental stenosis and occlusions of the distal SFA and proximal segment of PPA. The immediate results of this operation are comparable with the results of endovascu-lar procedures.
2. The planning of the operation requires a thorough pre-operative.
References:
1. Fowkes FG, Murray GD, Butcher I, et al. Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA. 2008; 300: 197-208.
2. Egorova NN, Guillerme S, Gelijns A, et al. An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety. J Vasc Surg. 2010; 51: 878-885.
3. Scheinert D, Scheinert S, Sax J, et al. Prevalence and clinical impact of stent fractures after femoropopliteal stenting. J Am Coll Cardiol. 2005; 45: 312-315.
4. Hassan AH, Ako J, Waseda K, et al. Mechanism of lumen gain with a novel rotational aspiration atherectomy system for peripheral arterial disease: examination by intravascular ultrasound. Cardiovasc Revasc Med. 2010; 11: 155-158.
5. Shammas NW, Coiner D, Shammas GA, et al. Percutaneous lower-extremity arterial interventions with primary balloon angioplasty versus SilverHawk atherectomy and adjunctive balloon angioplasty: randomized trial. J Vasc Interv Radiol. 2011; 22: 1223-1228.
6. Rocha-Singh KJ, Jaff MR, Crabtree TR, et al; Viva Physicians, Inc. Performance goals and endpoint assessments for clinical trials of femoropop-liteal bare nitinol stents in patients with symptomatic peripheral arterial disease. Catheter Cardiovasc Interv. 2007; 69: 910-919.
7. Laird JR, Kateen BT, Scheinert D, et al; RESILIENT Investigators. Nitinol stent implantation versus balloon angioplasty for lesions in the superficial femoral artery and proximal popliteal artery: twelve-month results from the RESILIENT ran-
domized trial. Circ Cardiovasc Interv. 2010; 3: 267276.
8. Ansel G. VIBRANT trial 3 year results. Presented at: VIVA; October 2012; Las Vegas, NV.
9. Saxson R. VIPER trial 1-year results. Presented at: VIVA; October 2012; Las Vegas, NV.
10. Dake MD, Ansel GM, Jaff MR, et al; Zilver PTX Investigators. Paclitaxel-eluting stents show superiority to balloon angioplasty and bare metal stents in femoropopliteal disease: twelve-month Zilver PTX randomized study results. Circ Cardiovasc Interv. 2011; 4: 495-504.
11. Cassese S, Byrne RA, Ott I, et al. Pacli-taxel-coated versus uncoated balloon angioplasty reduces target lesion revascularization in patients with femoropopliteal arterial disease: a meta-anal-ysis of randomized trials. Circ Cardiovasc Interv. 2012; 5: 582-589.
12. Cavallaro A, Sterpetti AV, Sapienza P, et al. How to avoid a difficult groin in redo arterial surgery: eversion endarterectomy of the proximal superficial femoral artery versus profunda femoris artery as inflow for distal bypass. Ann Vasc Surg. 2012; 26(3): 383-386.
13. Gabrielli R, Rosati MS, Vitale S, et al. Randomized controlled trial of remote endarterectomy versus endovascular intervention for TransAtlantic Inter-Society Consensus II D femoropopliteal lesions. J Vasc Surg. 2012; 56(6): 1598-605.
14. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endo-vasc Surg. 2007; 33 Suppl 1: S1-75.
Contacts
Corresponding author: Khorev Nikolay Ger-manovich, Doctor of Medical Sciences, Professor of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with the course of FVE of the Altai State Medical University, Barnaul.
656038, Barnaul, Lenina Prospekt, 40. Tel: (3852) 201256. Email: [email protected]
Beller Aleksandr Viktorovich, Doctor of Medical Sciences, Head of the Department of Vascular Surgery of the Multiprofile hospital of JSC Russian Railways at the Barnaul station, Barnaul. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 380000. Email: [email protected]
Konkova Victoria Olegovna, resident of the Department of Faculty Surgery named after Professor II. Neimark, hospital surgery with the course of FVE of the Altai State Medical University, Barnaul. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201256. Email: [email protected]
Belokrylova Yulia Gennadievna, assistant of the Department of Faculty Surgery named after Professor II. Neimark, hospital surgery with the course of FVE of the Altai State Medical University, Barnaul.
656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201256. Email: [email protected]
Shoikhet Yakov Nakhmanovich, corresponding member of RAS, Doctor of Medical Sciences, Professor of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with the course of FVE of the Altai State Medical University, Barnaul.
656045, Barnaul, Zmeinogorsky Trakt, 75. Tel.: (3852) 268233. Email: [email protected]
