Remote endarterectomy: Lessons learned after more than 100 cases

Bypass procedures have been the mainstay of treatment of extensive external iliac and superficial femoral artery (SFA) occlusive disease, particularly total occlusions. Since the early 1990s, reports from Europe have espoused the virtues of endarterectomy of the superficial femoral and iliac arteries from a small groin incision, but adoption in the United States has been limited. Over the past 4 years, we have explored the technical challenges and durability of this procedure and report our findings. Remote endarterectomy from an inguinal incision was the primary treatment option for all patients considered surgical candidates for vascular reconstruction of the external iliac and superficial femoral arteries. All data were entered into an outcomes database prospectively and reviewed retrospectively. After the procedure, duplex ultrasound surveillance was performed quarterly the first year and semi-annually thereafter. Remote endarterectomy was the planned procedure in 133 patients. The mean age was 68 years, 68% were men, and 31% were diabetic. The indications for the procedure were claudication in 57% and limb salvage in 43%. In 16 patients (12%), technical issues precluded the completion of the remote endarterectomy and a bypass was performed. Successful retrograde iliac endarterectomy was performed in 7 patients, SFA endarterectomy in 105 patients, and combined retrograde iliac and antegrade SFA in 5 patients. The average duration of the procedure was 162 minutes ± 69 minutes (SD). Half of the patients were discharged on the first postoperative day, and the average length of stay was 2.52 days. The mean follow-up was 19 months, with a primary patency of 70% at 30 months by life-table analysis. Limb salvage was 94%. Remote endarterectomy is a viable and durable alternative to standard bypass procedures. It has equivalent patency to published results of bypass or endovascular procedures of the external iliac and superficial femoral arteries and may soon replace bypass as the preferred procedure for long-segment occlusions of these vessels.