Isolated femoral endarterectomy: Impact of SFA TASC classification on recurrence of symptoms and need for additional intervention

ObjectivesAtherosclerotic occlusive disease of the femoral artery is associated with symptoms ranging from claudication to tissue loss. This study examined the clinical and hemodynamic outcomes of isolated femoral endarterectomy (FEA) as well as the predictors of symptom recurrence and need for further intervention.MethodsPatients who underwent an isolated FEA between January 2001 and June 2008 were reviewed. Concurrent superficial femoral artery (SFA) disease was classified into Trans Atlantic Inter-Societal Consensus (TASC) II categories based upon angiographic findings. Hemodynamic success (HS) was defined as a postoperative ankle-brachial index (ABI) increase of ≥0.15. Clinical improvement was classified by Rutherford criteria. Multivariate analysis was used to identify predictors of clinical failure and need for additional intervention (AI). Kaplan-Meier estimates were used to determine the likelihood of both over time.ResultsNinety-five patients (105 limbs) with a mean age of 68.3 ± 10.2 years were reviewed. Indications were severe claudication in 68 (64.8%) limbs and critical limb ischemia (CLI) in 37 (35.2%). Mean preprocedural ABI was 0.57 ± 0.25. The SFA-popliteal segment was classified as: normal in 34% of limbs, TASC A 23%, B 19%, C 9%, and D in 15%. One fatal myocardial infarction accounted for a procedural mortality of 0.95%. Morbidity was 6.7% (four hematomas and three wound infections) and mean hospital stay was 2.5 ± 3.1 days. Patency was 100% with a mean follow-up of 11 months (1-72). Complete resolution of symptoms was noted in 73.4% with some clinical improvement noted in 91% of limbs. HS was achieved in 85.1% with a mean ABI increase of 0.27 ± 0.20, and this correlated with ≥2 runoff vessels (odds ratio [OR] 0.20; 95% confidence interval [CI] 0.04-0.96; P = .045). Kaplan-Meier estimates revealed that 83.8% of patients with marked initial clinical improvement remained symptom free at 2 years, whereas only 28.6% in the group with mild and moderate initial response maintained their clinical status. Freedom from AI at 2 years was 61.8%. Multivariate analysis revealed that TASC C and D lesions (OR 9.3 [2.43-35.63] P = .001) and diabetes (OR 3.64 [1.01-13.15] P = .048) were predictive of recurrent symptoms while extensive endarterectomy and ≥2 vessel tibial runoff decreased the need for AI.ConclusionFEA can achieve excellent immediate clinical and hemodynamic outcome in patients with claudication and CLI; however, patients with diabetes and femoropopliteal TASC C and D lesions are likely to experience recurrent symptoms. Long-term symptomatic improvement is associated with the degree of immediate clinical success as well as the status of the run-off vessels. Limited FEA and poor tibial runoff are associated with the need for AI