Open and Endovascular Treatment of the Common Femoral Artery in a Tertiary Care Center.

Abstract

Objectives: Endovascular treatment of peripheral arterial disease (PAD) involving the common femoral artery (CFA) remains controversial. This study compares the perioperative and long-term outcomes of open and endovascular lower extremity revascularization (LER) involving the CFA.

Methods: A retrospective analysis of all patients undergoing LER for PAD in a tertiary-care center was performed. Patients were divided into the open or endovascular group based on the first LER that involved the CFA. Patient characteristics were compared, and outcomes analysis focused on the ipsilateral CFA reintervention rate. Multivariable regression was used to determine the association between the CFA revascularization strategy and CFA reintervention. Analysis was stratified based on indication.

Results: A total of 1,954 patients underwent 4,879 LER (including all reinterventions) between 2013-2020. The CFA was treated in 22.9% of patients (N=447/1954) and 15.0% of LER procedures involved the CFA (N=734/4,879). Patients treated for CLTI were more likely to undergo open CFA treatment compared to patients with claudication (60.6% vs 42.7%, p<0.001). Patients treated for CLTI with endovascular therapy were more likely to be male compared to patients treated with open surgery (66.7% vs 51.2%, p=0.025). On the other hand, patients treated for claudication with endovascular therapy were more likely to have CAD (64.9% vs 50.5%, p=0.027) and diabetes (49.3% vs 33.0%, p=0.013) compared to open surgery. There was no difference in perioperative amputation or mortality but patients undergoing CFA endarterectomy were more likely to have post-operative bleeding in the claudication group as well as wound infections and longer hospital length of stay in both indication groups. On follow up, patients receiving endovascular LERs were more likely to require an ipsilateral CFA reintervention for both claudication (35.1% vs 21.0%, p=0.019) and CLTI (33.3% vs 20.9%, p=0.043) with no difference in major amputation or survival between the groups. Among claudicants, CFA endarterectomy was significantly more likely in patients initially treated with endovascular therapy (conversion to open endarterectomy) compared to patients initially treated with open surgery (redo endarterectomy) (14.9% vs 5.0%, p=0.015). Multivariable logistic regression revealed an independent association between endovascular therapy and CFA reintervention for claudication (OR= 2.29 [1.16-4.66]) and CLTI (OR=2.38 [1.18-4.90]). Kaplan-Meier analysis showed no difference in MALE-free survival.

Conclusion: Endovascular treatment of the CFA is associated with higher reintervention of the CFA regardless of indication. CFA endarterectomy is associated with higher perioperative complications and longer hospital stay. Understanding the severity of CFA disease could improve patient selection for optimal therapy.