Remote Endarterectomy: The Third Pathway for Arterial Revascularization
Case Presentation - February 2013
W. Michael Park, MD
As patients with longstanding peripheral vascular disease are living longer with their disease, we are referred patients who are at the end of the line regarding further bypass operations and endovascular procedures, usually as a result of a lack of bypass conduit and failed interventions, and are facing limb loss or worse.
There are a finite number of ways of dealing with an occluded artery. One is to bypass it using either the patient’s own veins or to use tubes of artificial graft materials, or as a last resort, donor arteries and veins. The second option is to open the arteries by pushing aside the occlusive plaque with balloons, stents, and more recently stent grafts, which are graft material mated to stents. Even newer therapies include devices to drill through the plaque by pulverizing, cutting, or burning it. All of these treatments have varying degrees of success, durability, and invasiveness, which refers to the amount of cutting, blood loss, and time in the operating room, often under general anesthesia.
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If we group the mentioned treatments under two categories 1) bypass operation and 2) endovascular therapies, we'd be overlooking an important third category of treatment, the endarterectomy. Before the advent of bypass grafts, this was often the only option for treating occluded arteries.
The endarterectomy and its modern incarnation, the remote endarterectomy (EndoRE), offer an important third option in revascularization particularly when the first two options have been attempted. It has the advantage of not relying on artificial materials, making it suitable for application in infection. Endarterectomy involves removing the obstructive plaque surgically, reopening the previously occluded artery (main figure). It is often technically feasible to remove occlusive stents.
For example, it is common to see patients who have undergone prior stenting who return with these stents occluded (figure 1). If they don't have available vein, their options can be limited, but with this third option of remote endarterectomy, the occlusive plaque and stents can be removed (figure 2). This restores latency of the previously occluded artery (figure 3), all done from one groin incision of approximately 4 inches in length (figure 4).
The other scenario is when a patient presents with infected graft. The second patient (figure 5) presented several weeks after aortobifemoral bypass done at another institution and developed a groin wound infection. The CT scan showed the infection to be localized to the groin, and that the native external iliac artery (EIA), while occluded, was suitable for reopening via EndoRE. The patient's graft was explored in the right pelvis adjacent to the occluded EIA and found to be well incorporated. A standard endarterectomy was started in the external iliac artery (figure 6) and the graft transected and anastomosed to the external iliac artery, which had been partially reopened (figure 7). This wound was closed to isolate it from the infected wound. From the groin wound, the graft segment was pulled out of the pelvis (figure 8), and the common femoral and external iliac artery plaques were removed by EndoRE (figure 9 and 10). The common femoral artery was then repaired with a vein patch and the artery covered with a transposed sartorius muscle flap (figure 11).
EndoRE allows for a less invasive revascularization option. It is durable [ref 1] compared to intervention on TASC D lesions (long segment occlusions), comparing favorably to bypass with prosthetic and having acceptable patency rates [ref 2]. While not suitable for all cases or as a primary revascularization option, endarterectomy remains a useful part of the vascular surgery armamentarium.
- Gabrielli R. et al. Randomized controlled trial of remote endarterectomy versus endovascular intervention for TransAtlantic Inter-Society Consensus II D femoropopliteal lesions. J Vasc Surg 2012;56:1598-605.
- Gisbertz SS. et al. Remote endarterectomy versus supragenicular bypass surgery for long occlusions of the superficial femoral artery: medium-term results of a randomized control trial (The REVAS Trial). Ann Vasc Surg 2010;24:1015-23.