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Management of superficial femoral artery occlusive disease Vascular team work Al-Hussein University Hospital Dr. Mahsoub M Amin Head of General and Vascular Surgery Department Al-Azhar University (Assuit)
INTRODUCTION • The prevalence of intermittent claudication in men aged 55- 74 years is 4.5 per cent and a common cause of such claudication is superficial femoral artery (SFA ) occlusive disease. • Therapeutic options range from conservative treatment to endovascular intervention and surgical bypass or endarterectomy.
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INTRODUCTION • Intermittent claudication is usually treated conservatively • PTA should be considered for TASC-II A &B • Bypass surgery for TASC-II C & D
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The aim To evaluate whether PTA or vein bypass is the most successful treatment for patients with an isolated SFA lesion The goals of treatment are: to provide pain relief, promote wound healing, and preserve limb function, whilst minimising overall cardiovascular risks.
METHODS • The study included 355 patients, it was carried out in AL-Azhar university hospitals 5 years from 2005 to 2010 . • Inclusion criteria: intermittent claudication not responding to conservative therapy for at least 3 months and a stenosis or occlusion of the SFA .
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METHODS Exclusion criteria : • A hemodynamically significant stenosis of the aorto-iliac tract • Absence of patent crural arteries, • Life expectancy less than one year due to concomitant diseases and contra-indication for PTA or surgery such as severe cardiopulmonary diseases .
patients were divided into two groups • The 1st group (TASC-II A &B ): 145 pt were treated by percutaneuos tansluminal angioplasty by balloon dilatation except in some cases with complications as dissection, restenosis , perforation treated by stent . • The 2nd group (TASC-II C &D ): 210 pt were treated by femoro popliteal bypass surgery
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• Full records of all patients were done: Patency of the treated vessel or bypass was established via duplex scanning by calculating the peak systolic velocity (PSV) and the end diastolic velocity (EDV). • Both parameters were used to trace the diameter reduction of the revascularized artery . An increase of the PSV greater than 2.5 at a stenosis site was defined as hemodynamically significant.
PTA
Bypass
Number
145
210
Male/Female
90/55
160/50
Age median (range)
68 (45–84)
66 (42–83)
Medical history Previous non vascular surgery 22
19
Hypertension
47
28
Hyperlipidaemia
28
16
Diabetes
35
39
Myocard infarct
22
14
Stroke
3
4
Smoking
32
45
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PTA
Bypass
Category 3
35
53
Category 4
33
87
Category 5
37
62
Category 6
40
8
Ankle Brachial index % (range)
55 (15–84)
58 (22–92)
Stenosis
105
20
Occlusion
35
190
1
55
74
2
42
63
3
48
73
Rutherford classification
Lesion
Number of patent crural arteries
Critical Case for bypass surgery
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CT Angiography before operation
Exposure of common femoral ,superficial femoral and profunda femoris arteries
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Exposure of popliteal artery
Harvesting of long saphenous vein
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Dilatation and preparation of long saphenous vein
Proximal and distal anastomosis between long saphenous vein and both femoral and popliteal arteries
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Closure of wounds
Other case in which Anastomosis done by synthetic graft
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Case 1
Case 2
A-occluded distal SFA,popliteal artery B,C-balloon dilatation D-post balloon dilatation
A,B-occluded distal SFA C,D-post balloon dilatation
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Case 3
A-occluded distal SFA B-during balloon dilatation C,D-post balloon dilatation
Case 4
A-occluded distal SFA B-during balloon dilatation C,D-post balloon dilatation
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Case 5
A-stenosis of SFA B-insertion of stent C,D-after insertion of stent
Case 6
A-stenosis of SFA B-insertion of stent C,D-after insertion of stent
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Case 7
A-stenosis of SFA B-insertion of balloon C,D-post balloon dilatation
Case 8
A-stenosis of SFA B-insertion of balloon C-post balloon dilatation
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Case 9
Case 10
A-stenosis of SFA B-post balloon dilatation and stent insertion
A-short stenotic segment of mid SFA B-insertion of balloon C-post balloon dilatation
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Case 11
Case 12
A-stenosis of SFA B-insertion of balloon C-post balloon dilatation
A-occluded SFA B- during balloon dilatation
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Case 13
case 14
1- long angioplasty balloon dilatation 2- completion angiogram
Narrowed superficial femoral artery before & after dilatation
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Case 15 A-occluded SFA B- post balloon dilatation and stent insertion
Case 16 A-occluded distal SFA B-post balloon dilatation and stent insertion
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Case 17 A-stenosis of SFA B-post balloon dilatation and stent insertion
Case 18
Diffuse intense disease of the superficial femoral artery resolved by implanting a stent.
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Results 210 surgical bypass operations : 160 male and 50 female patients median age was 66 years SYMPTOMS 70 patients had tissue loss (ulcer or gangrene) . 87 patients had rest pain . 58 patients had disabling claudication only .
MORTALITY • 30-day operative mortality : 3.8 % myocardial infarction (n=2), congestive heart failure (n=1), cerebrovascular accident (n=2), pneumonia (n=2), mesenteric infarction (n=1).
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• Limb salvage rates: were 92 % , 82% and 78% at 1 , 12 and 36 months, respectively. • median postoperative hospital stay :10 days. • Primary graft patency rates: at 1, 12 and 36 months were 91%, 63% and 47% respectively . • Fifty patients underwent secondary intervention or further surgery in the presence of ischaemic symptoms due to graft failure. • Subsequent secondary graft patency rates: at 1, 12 and 36 months were 95%, 74% and 58% respectively. • Patient survival rates: were 82% and 66% at 1 and 3 years, respectively.
PTA group • 145 limbs : 90 males and 55 females. • median age (68 years). • Disabling claudication in 100 pt. , Tissue loss in 20 and rest pain in 25 . • The median ABI was 0.45.
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• 30-day mortality in those having PTA was lower than that of the surgical group ( 2 %). • The median hospital stay (2 days) was shorter. • Complications included : -Myocardial infarction (n=6), -Wound haematoma (n=10), -Pseudoaneurysm (n=7), -Thromboembolic complications (n=5).
• After PTA, - 61% of the treated limbs required no further procedure; - 30% of patients without clinical improvement underwent bypass surgery due to multi-segment occlusive disease distal to the target lesions . - 1% of patients : repeated PTA was performed . - 8% of patients had multiple co-morbidities or absence of run-off arteries . • Overall limb salvage rate was 93%, and 89% at 1,and 3 years, respectively. This was significantly better than that for bypass surgery up to 3 years.
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Conclusion
• Bypass and percutaneous transluminal angioplasty are complementary. • Balloon angioplasty carries the potential advantages of lower procedural morbidity and mortality , and shorter hospital stay. Moreover, it is repeatable, a suitable vein is not required, and does not seem to jeopardise subsequent surgery . Nevertheless, its benefits seem less durable.
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