Deep femoral artery: an option as inflow site in infragenicular bypasses

Abstracts

CONTEXTO: Na isquemia crítica, a artéria femoral profunda pode tornar-se a opção mais distal como origem de fluxo para derivações distais em casos de oclusão da origem da artéria femoral superficial associada a prega inguinal hostil. OBJETIVO:Avaliar, retrospectivamente, a artéria femoral profunda como doadora de fluxo para derivações infrageniculares. MÉTODOS: De 2000 a 2005, 129 derivações infrageniculares apresentaram anastomose proximal nas artérias femorais, comum (40), superficial (72) e profunda (17). O presente estudo teve como foco a artéria femoral profunda, e suas indicações foram: prega inguinal hostil (seis casos), limite da extensão do substituto (seis casos) e ambos os fatores (outros cinco casos). Foram abordadas a primeira e a segunda porção em 12 casos e a terceira porção em cinco casos. As cirurgias foram secundárias em 47% dos casos, e os substitutos utilizados foram veias do membro superior em 11 casos, safena interna em cinco e safena externa em um caso. RESULTADOS: No total dos enxertos (129), as estimativas de perviedade primária e salvamento do membro foram: 68,0% e 84,7%, respectivamente, com erro padrão (EP) aceitável (0,1) em 36 meses. Quando o grupo foi estratificado, as artérias femorais comum, superficial e profunda apresentaram resultados comparáveis de perviedade primária (63,3, 70,2 e 64,7%; p = 0,63) e salvamento do membro (83,1, 82,4 e 92,3%; p = 0,78). A perviedade dos enxertos com origem nas porções proximal e distal da artéria femoral profunda, bem como das cirurgias primárias e secundárias, foram comparáveis, sem diferença estatística significante (p = 0,89 e p = 0,77, respectivamente). CONCLUSÃO: A artéria femoral profunda mostrou ser acessível e efetiva como origem de fluxo de enxertos infrageniculares, com resultados satisfatórios de perviedade e salvamento do membro.

Artéria femoral profunda; anastomose proximal; derivações infrageniculares

ORIGINAL ARTICLE

Deep femoral artery: an option as inflow site in infragenicular bypasses

Francisco Cardoso Brochado Neto^I; Ivan Benaduce Casella^I; Marcelo Fernando Matielo^II; Tulia Brasil Simões^III; Arnaldo Rolim Ricartte^III; Ricardo Lacerda^III; Luiz Carlos Bergamo^IV; Roberto Sacilotto^V

^IAssistant physician and preceptor of residents, Vascular Surgery Service, Hospital do Servidor Público Estadual de São Paulo (HSPE-SP), São Paulo, SP, Brazil

^IIAssistant physician and responsible, Nursing Unit, Vascular Surgery Service, HSPE-SP, São Paulo, SP, Brazil

^IIIFormer resident, Vascular Surgery Service, HSPE-SP, São Paulo, SP, Brazil

^IVPhysician. Head, Vascular Surgery Service, HSPE-SP, São Paulo, SP, Brazil

^VDirector, Vascular Surgery Service, HSPE-SP, São Paulo, SP, Brazil

Correspondence

ABSTRACT

BACKGROUND: Deep femoral artery can be the most distal technical option as donor site in patients with critical limb ischemia presenting superficial artery occlusion and hostile groins.

OBJECTIVE: To retrospectively assess the deep femoral artery as an inflow site for infragenicular bypass grafts.

METHODS: From 2000 to 2005, 129 infragenicular bypass grafts with proximal anastomosis located in femoral arteries were performed. Forty were located in the common femoral artery (CFA), 72 in the superficial femoral artery (SFA) and 17 in the deep femoral artery (DFA). Indications for using the DFA as inflow were hostile groin (six cases), limited arterial substitute length (six cases) or both (five cases). Anastomosis site was located in the first or second portion in 12 cases, and in the third in five cases. The surgery was secondary in 47% of the cases, and the arterial substitutes used were arm veins (11), greater saphenous vein (five) and lesser saphenous vein (one).

RESULTS: Primary patency and limb salvage rates were 68.0 and 84.7%, respectively, with acceptable standard error (0.1) in 36 months. The results of patency divided by inflow artery were similar (CFA, 63.3%; SFA, 70.2%; DFA 64.7%; p = 0.63), as well as limb salvage rates (CFA, 83.1%; SFA, 82.4%; DFA 92.3%; p = 0.78). Analyzing the deep femoral group, no difference of patency rates was observed when the anastomotic site was compared (proximal vs. distal portions of the DFA) or between patients with or without previous grafts. (p = 0.89 and 0.77, respectively).

CONCLUSION: Deep femoral artery is a feasible and effective option as donor site for infragenicular bypass grafts, with satisfactory patency and limb salvage rates.

Keywords: Deep femoral artery, proximal anastomosis, infragenicular bypass grafts.

Introduction

Preferential use of the common femoral artery (CFA) as an origin of infrainguinal graft flow started losing power after the publications by Veith et al.,¹ Mills et al.² and, more recently, Ballota et al.,³ in a randomized study, which used other arteries, such as superficial (SFA) and deep (DFA) femoral arteries, without proximal disease, had results of graft function similar to those of the CFA.

Some patients with occlusion of the femoropopliteal segment required a new surgery in the hostile inguinal crease⁴ with or without infection, in unfavorable conditions for conventional anterior access to the CFA. Others had substitute limitations in the lack of an internal saphenous vein, resulting in use of less extensive alternative substitutes such as upper limb veins (ULV)⁵ or external saphenous veins.⁶ In these situations, DFA may seem as the most distal and preserved option for proximal anastomosis of grafts. This study retrospectively evaluates DFA as a donor of flow for infragenicular bypasses.

Method

A total of 129 infragenicular bypasses out of 497 infrainguinal revascularizations were analyzed at Hospital do Servidor Público Estadual de São Paulo from January 2000 to December 2005. Bypasses with the following characteristics were selected for the study: origin in common, superficial and deep femoral arteries; autogenous grafts; and infragenicular recipient arteries. The patients' clinical and demographic data are summarized in Table 1.

Femoral arteries were the donor arteries in 129 bypasses: superficial in 72 cases (55.8%), common in 40 (31.0%) and deep in 17 (13.2%). There was no statistical difference between the subgroups as to presence of demographic and clinical variables. The infragenicular popliteal, fibular and tibial arteries were the most widely used recipient arteries. Grafts were autogenous in all cases; the internal saphenous vein was used in 108 of them, external saphenous vein in two, upper limb in 16 and combination of internal saphenous vein and upper limb in three cases. The vein implant technique was preferentially removal, non-reversed and devalvulated, using Mills valvulotome in 96 cases and reversed in 32. In one case the in situtechnique was used, according to Table 2. Indications for use of DFA as origin of flow were hostile inguinal crease in six out of 17 cases; limitation of graft extension in six cases; and presence of both factors in five cases. The DFA was divided into three regions: proximal, extending from its origin until the lateral circumflex artery of the femur; medial, extending from the lateral circumflex artery of the femur until the second perforating branch and entering the femoral triangle; and distal, after the second perforating branch.⁷ Proximal graft anastomoses were performed in the proximal and medial regions in 12 cases, and in the distal region in five cases. Use of the DFA third region (distal) resulted from the impossibility of accessing the proximal segments of the artery.

Recipient arteries of bypasses originating in the DFA were popliteal in five cases, anterior tibial in five, posterior tibial in three (Figure 1), fibular in two, sural genicular in one and anterior graft (superior femoral - tibiofibular trunk) in one case. Out of 17 DFA bypasses, eight (47%) were secondary surgeries, six due to occluded distal graft, one due to surgical wound infection after thrombectomy and one to avoid aortofemoral graft exposure. Most grafts were arm veins (11 cases): basilic vein in three cases, cephalic vein in four and basilic-cephalic loop in four, all implanted in leg arteries. The remaining grafts were internal saphenous vein in five cases and external saphenous vein in one. Sixteen veins were placed in a removed and devalvulated manner, and one reversed. The surgeries were performed with image magnification (3x).

Arteriographic study of the deep femoral artery was preferentially performed in anteroposterior and oblique projections.

The DFA portion used as graft source was chosen according to the technical criteria of absent proximal disease or stenosis of up to 20% of the lumen,^2,3 prioritizing initial portions whenever possible.

To approach the first and second portions of the DFA, preference was anteromedial access for primary surgeries, performed medially to the sartorius muscle. In cases of hostile inguinal crease, anterolateral access was used, laterally to the sartorius muscle (Figure 2).

For the third portion, posteromedial access of the thigh was used through a longitudinal incision performed between the long adductor and gracile muscles. The long adductor muscle is detached superiorly, and the adductor longue and brevis are detached inferiorly, thus allowing DFA exposure, which can then be isolated below the second perforating branch in its distal portion⁸ (Figure 2).

All grafts entered the surveillance program of autogenous grafts. Analysis of results was performed using life table (Kaplan-Meier), and comparison of results using the log ranktest, with the software Statistical Package for the Social Sciences 0(SPSS), version 10.0.

Results

The patients submitted to the 129 bypasses were followed for 36 months, with mean follow-up of 23.8±18.7 months. In the total group, there were 34 graft occlusions and 18 major amputations, events that caused estimates of 68.0% primary patency and 84.7% limb salvage, with acceptable standard error (SE) lower than 10%. Estimates of primary patency were stratified according to proximal anastomosis, and the results were 63.3% for the DFA, 70.2% for the superficial femoral, and 64.7% for the deep femoral, with SE = 11%, but with no significant statistical difference between such values (log rank, p = 0.63; Figure 3).

Limb salvage estimates had no significant variation between bypasses: CFA, 83.0%; SFA, 82.0%; and DFA, 92.0%, respectively, with SE < 10% (p = 0.78; Figure 4).

Group survival in 36 months was 64.4%. Sixteen patients died during hospital stay, while 27 individuals died in the follow-up.

Follow-up estimate of the patients in the period was 89% in the total group, with the following distribution for the subgroups: CFA, 91.0%; SFA, 89.0%; and DFA, 100.0%.

In the group of bypasses originating in the DFA (17), there were four graft occlusions, two bypass reviews and two major amputations, with estimates of 64.7% primary patency, 70.6% assisted primary patency, and 92.0% limb salvage.

In the surveillance program, no graft with risk for occlusion was detected by lesion in its body in the follow-up period. However, two cases were detected with hemodynamically significant flow changes: one case in the early postoperative period, with proximal graft flow due to occlusion of a small distal juxta-anastomotic segment of the sural genicular artery, which was submitted to graft extension with basilic vein; in the other case, detection of significant proximal stenosis, which resulted in need of reviewing the donor flow, in which an external iliac graft was performed (patent graft, second portion of fibular DFA) with superficial femoral artery submitted to endarterectomy, successful until the end of the study period. These reviews caused an improvement from primary patency to assisted primary patency in the clinical variables infrapopliteal arteries, arm veins, proximal and distal portions of the DFA, primary and secondary surgeries, and trophic lesion, but without significant statistical difference (Table 3).

Grafts with proximal anastomosis in the DFA had a better patency when implanted in the distal popliteal artery (80.0%; SE = 17%) in relation to infrapopliteal arteries (50.0%; SE = 14%), but without significant statistical difference (p = 0.29).

The present ULV in 11 out of 17 DFA grafts showed patency estimate (54.5%; SE = 15%) equivalent to the internal saphenous vein (60.0%; SE = 21%), without significant statistical difference (p = 0.89).

The five grafts originating in the distal portion showed better estimate of primary patency (60.0%; SE = 21%) than the 12 grafts in the first and second portions (58.3%; SE = 14%), but with no significant statistical difference (p = 0.89).

Surgical indication due to rest pain or ulceration did not influence the primary patency of grafts (54.5%; SE = 19% and 66.7%, SE = 13%, respectively), with no statistically significant differences (p = 0.67).

In the evaluation of graft patency of secondary (62.5%; SE = 15%) or primary surgeries (53.3%, SE = 15%), there was no statistically significant difference (p = 0.77).

In the evolution of surgical scar of previous accesses in the first and second portions and the posteromedial access of the third portion, there was hyperemia of surgical scars in 20% of cases, but there were no hematomas, necrosis of surgical wound edges or exaggerated complaint of pain in the early postoperative period.

Discussion

Authors such as Farley et al.,⁹ DePalma et al.⁴ and Aston et al.¹⁰ reported the lowest atherosclerotic impairment of the DFA in relation to the superficial femoral artery in cases of critical ischemia, showing its potential usefulness as donor of graft flow, both in primary and in secondary surgeries.

Beales et al.¹¹ considered that anteroposterior arteriographic projection underestimates stenosis in the origin of the deep femoral artery and suggested an oblique projection of the coxofemoral region for a better evaluation of DFA disease. In any of these cases the color-flow Doppler ultrasound was used as initial study for DFA evaluation, although in patients with restriction against use of iodinated contrast distal grafts were indicated using only arterial ultrasonography.¹² Therefore, a good angiographic study is essential to verify whether the DFA is adequate for use.

Darling III et al.¹³ published 563 cases showing that the DFA free from proximal disease is as useful as the common and femoral superficial arteries in arterial reconstructions with satisfactory function in 76%. The in situ technique was used in most distal bypasses, and difficulties inherent to this technique were described, such as calcification of the DFA or occlusion of the superficial femoral artery, making proximal anastomosis difficult. The authors justified that use of the DFA medial portion leaves anastomosis free from tension with good function outcomes. Mills et al.² reported use of DFA in the medial and distal portions in 56 arterial bypasses, with satisfactory outcomes of secondary function (96%) in 36 months; most were through anterior access, and only two used posteromedial access. In this study, there was assisted primary patency of 70.6%.

Mello et al.,¹⁴ in their large sample of infrainguinal bypasses with internal saphenous vein in situshowed that the deep femoral artery was the second most widely used artery as proximal anastomosis of grafts, verifying frequency of use (23%) and importance in alternative situations. They showed good graft patency outcomes in the total group; however, they did not specifically analyze the patency of grafts that had proximal anastomosis in the deep femoral artery.

In the present study, there were better estimates of primary patency for grafts originating in the superficial (70.2%) and deep (64.7%) femoral arteries in relation to the common artery (63.3%), but with no significant statistical difference (p = 0.63; Figure 3), a condition similar to previously mentioned publications.^2,3,13

However, in this study the DFA was used in its three portions, which allowed us to evaluate execution and usefulness of accesses, as well as their outcomes in a small sample, perhaps requiring increase of its indication as flow donor, since it accounted for 13% of total grafts, against 23% in the group of Mello et al.,¹⁴ 25% in the group by Mills et al.² and 24% in the group by Darling III et al.¹³

There is a concern as to use of distal portions of the DFA due to the natural evolution of the atherosclerotic disease. Darling III et al.¹³ reported that 1.6% of cases required proximal procedures due to hemodynamically significant disease in lesions that were not important initially, when they used the distal portion of the DFA. In our sample, there was only one case (5%) of proximal stenosis, which required review. Mills et al.² reported a single case of proximal native artery review, a fact that was attributed to clamp lesion, and not to progression of the atherosclerotic disease. Such concern is reduced if we consider that presence of hemodynamically significant intimal hyperplasia detected in autogenous grafts in the first surveillance year by duplex scan is approximately 25%,^15,16 therefore higher than the rates of disease progression, a fact that allows us to try to use sources of more distal arteries and less extensive grafts.

Another good indication for use of DFA distal portions is presence of proximal graft in the femoral aortoiliac segment, whose exposure, whenever possible, should be avoided due to higher risk of infection, a condition that also prevents lesions in neighboring structures (veins, nerves) during dissection of the fibrosed area.

As to the technique of vein implantation in infragenicular bypasses, studies published by several authors^17-19 have shown that the results are similar when the surgical team uses the technique they have wider experience. In our series, we had the opportunity of using both techniques, according to the surgeon's preference, and found better performance of saphenous veins placed in the removed and devalvulated manner (79.3%) in the total group when compared with reversed (41.4%), results that had statistically significant difference (p < 0.01).

The number of occlusions in grafts whose proximal anastomosis originated in the first and second portions of the DFA had failure rates similar to those that had proximal implantation in the distal portion, a fact that caused equivalent estimates of primary patency in the use of any DFA portion available (p = 0.89).

Use of the third DFA portion through posteromedial access was reported by Nunes et al.⁷ and showed good outcomes in five cases with a 6-month follow-up. Brochado-Neto et al.²⁰ published a sample of 11 grafts originated in the distal portion, reporting good outcomes of limb function and preservation.

The posteromedial access allows for use of a less extensive segment of autogenous vein, which is positive for the short- and medium-term graft performance, both in distal beds with good flow^2,21 and in beds with high peripheral resistance. There were two cases in this study: one of them draining to an isolated popliteal segment^22-24 and another to a sural genicular artery.²⁵ Use of selected vein segments can reduce risk of preexisting lesions unnoticed in the graft during the surgery.²⁶

Logerfo et al.²⁷ described the technique of using the cephalic and basilic vein loop connected through the medial elbow vein in a single segment, a condition that results in a better use of the ULV extension, and that was satisfactorily used in four cases of this study.

No stents were used as substitutes, avoiding placement of a synthetic material close to infection areas or in reoperations. Autogenous material was chosen, such as the ULV, which is known to have better function results in distal grafts than the stent.^28-31

Primary and secondary surgeries had satisfactory and equivalent results, in agreement with the publications by Whittemore et al.³² and Belkin et al.,³³ who reported about the importance of treating critical ischemia in reoperations.

Autogenous graft surveillance as recommended by TASC³⁴ caused two graft reviews, which were successfully performed, improving assisted primary patency, a situation that is supported by publications that report better results of graft reviews in relation to graft thrombectomy or early reoperations.^35-37

We are aware of surgeons' concern in DFA approach. However, current publications have shown similar results in DFA function compared with other donor arteries for graft flow, and considering the small progression rate of proximal atherosclerotic disease, the DFA could be used more frequently, in its three portions, even in primary surgeries, such as abdominal apron, a condition that often scarifies the inguinal crease and is a focus of surgical wound infection.

Conclusion

The results of this study showed good DFA performance as donor of graft in its three portions according to the outcome variables. They also showed that its use is safe and feasible in varied unfavorable situations to conventional accesses in terms of origin of distal grafts.

References

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Publication Dates

• Publication in this collection
  08 Dec 2008
• Date of issue
  Sept 2008

History

• Received
  11 Oct 2007
• Accepted
  19 May 2008