An old technique comes back to the future.
The possibility of vascular reconstruction for occlusive disease was born of the realization that plaque could be removed from vessels by utilizing the natural cleavage plane between the plaque and the deep media/adventitia layer. The first procedures to treat occlusions of the femoral and iliac arteries were endarterectomy procedures done in 1947 by João Cid dos Santo, and by Wiley et al in 1951.1,2 This was the birth of surgical techniques for vascular occlusive disease. It was not until the advent of prosthetic surgical grafts that bypass techniques for occlusive disease began to be explored and eventually dominate the surgical landscape. Today, patients with occlusive disease are generally asked to choose between large open procedures with significant morbidities, and percutaneous procedures with limited durability. Endarterectomy maintains a prominent place in the armamentarium of every vascular surgeon, but only as a limited open technique for carotid surgery or to enhance the anastomotic site during bypass procedures. Few, if any, of today’s vascular surgeons recall the use of endarterectomy for extensive iliofemoral procedures. Remote endarterectomy represents the fusion of the fundamental technique of endarterectomy with new endovascular techniques and tools.
WHY REMOTE ENDARTERECTOMY?
Remote endarterectomy offers an autogenous revascularization technique that removes essentially all of the atherosclerotic material in the affected vessel, in effect, “restarting” the vessel from the standpoint of atherosclerotic occlusion. As opposed to atherectomy, which removes minute amounts of plaque that represent <1% of the total disease burden, this technique removes virtually all of the disease. As a result of the dilatation that vessels undergo in response to the initial stages of atherosclerotic occlusion (ie, adaptation), the lumen after remote endart-erectomy is generally in the range of 130% to 150% of the lumen size of the original vessel, providing for a large margin of safety and redundancy in the face of restenosis.3 Restenosis occurs frequently in these endarterectomized segments but is usually focal. These focal areas can be discovered through routine ultrasound surveillance of treated segments and percutaneous dilatation and stenting. Most of these restenotic lesions occur in the first 12 months after the procedure and, from that point on, the treated segment rarely develops new lesions and becomes completely reendothelialized.4 Remote endarterectomy is also the procedure of choice as an initial therapy because it is 100% autologous and can be very durable. If it is not durable, it does not preclude the use of other options for revascularization, including stent/angioplasty, endografting, and conventional bypass surgery.
Remote endarterectomy is defined as the removal en bloc of a long-segment occlusion from a single entry point into the vessel. Typically, this involves long-segment occlusions of either the external iliac artery or the superficial femoral artery (SFA), but the fundamental aspects of the procedure could be adapted widely to other vascular beds as well. The procedure for SFA occlusive disease is performed as follows:5
(1) Exposure of the artery: The femoral artery is exposed and controlled with loops proximally and distally.
(2) Arteriotomy and initiation of endarterectomy: An arteriotomy is performed and the dissection plane between the plaque and the adventitia is initiated. This plane is developed circumferentially at the orifice of the vessel to be disobliterated endarterectomized and transected proximal to the orifice.
(3) Remote endarterectomy. A ring stripper (eg, Vollmar Dissector, Aesculap, South San Francisco, CA) is chosen to match the diameter of the plaque (Figure 1). It is placed in the dissection plane around the plaque and advanced down the occluded vessel segment under fluoroscopic guidance to the point at which reconstitution of the vessel was noted on preoperative arteriography.
(4) Distal plaque transection. A MollRing Cutter (Vascular Architects, Inc., Santa Rosa, CA), or similar device, is advanced over the same tube of dissected plaque. The two rings of the cutter are actuated to transect the distal end of the plaque. The tube of plaque is removed en bloc (Figures 2,3).
(5) Gaining access to the true lumen distally. The true lumen of the distal vessel is accessed with the necessary guidewires, catheters, or guiding balloons. A balloon is often useful for centering the guidewire in the lumen and enhancing access of the true lumen instead of the dissection plane (Figure 4).
(6) Distal endpoint fixation. A self-expanding stent sized to the endarterectomized segment diameter is deployed over the distal transection site to “tack down” the plaque at the transection site and to prevent a flap from obstructing the lumen (Figure 5).
A 55-year-old, white man had severe internal iliac artery disease and short-distance claudication. The right SFA was diffusely diseased, with multiple severe stenotic areas that were not occluded, but through which it was difficult to pass a 5F catheter. Remote endarterectomy yielded a widely patent SFA with an internal diameter of 8 mm to 9 mm and palpable pedal pulses. At 3-year follow-up, there was no stenosis (Figure 6A-D).
A 71-year-old, black woman had severe peripheral vascular disease and a large variety of serious comorbid conditions related to previous colectomy and ileostomy. The patient presented with near complete iliac occlusion bilaterally, and heel ulcers bilaterally. Remote endarterectomy of both external iliac arteries was performed with stenting of the common iliac segments. All foot wounds healed, and the result was durable at 3-year follow-up, with one revision that required dilatation of left external iliac artery (Figure 7A,B).
A 61-year-old, white woman, who was otherwise in good health, had short-distance claudication and a complete right external iliac occlusion. Remote endarterectomy was performed through a small femoral incision under local anesthesia. A 10-cm-long section of plaque was removed. There was no requirement for placement of a stent or any other device. The result was a 9-mm external iliac diameter, as determined by IVUS measurement. The patient was discharged 16 hours later and had no recurrence at 4-year follow-up (Figures 8A,B).
BEST OF BOTH WORLDS
Remote endarterectomy provides an opportunity to provide the best of both worlds to the patient with occlusive disease. Although it requires an incision, the incision is small and can be done under local anesthesia with same-day discharge. A severely diseased vessel can be made nearly disease-free and allow a “new playing field” for re-endothelialization to take place. It also allows for a far better environment for the application of new endovascular therapies (eg, stents, coated stents, peripheral endografts, cryotherapy, etc.).6 As an initial form of therapy, it leaves open and enhances the outcome of any procedure that might be performed later. From a single access point in the common femoral artery, a patient can be revascularized from the aorta to the distal popliteal artery.
Remote endarterectomy suffers from its image as an old technique and from the lack of dedicated medical device development to make its performance more reliable. The rebirth of remote endarterectomy is made possible by the marriage of open endarterectomy with the minimally invasive and remote aspects of fluoroscopically guided endovascular procedures that make remote endarterectomy possible. New endovascular devices (eg, stents, endovascular grafts, specialized compliant and noncompliant balloons) also play critical roles in allowing the procedure to be developed and refined. The future is bright for this technique because of its robust fundamentals and outcome coupled with the prospects for devices specifically designed to be used in the unique setting of an endarterectomized vessel. It is not difficult to image special linings, gene-therapy delivery systems, and modified drug-eluting stent delivery systems to build upon the already excellent results achieved with this technique.
David H. Deaton, MD, is Chief of Endovascular Surgery at Georgetown University Hospital in Washington, DC. He holds no financial interest in any product or manufacturer mentioned herein. Dr. Deaton may be reached at (202) 687-1265; firstname.lastname@example.org.
1. dos Santos JC. Sur la desobstruction des thromboses arterielles anciennes mem. Acad Chir. 1947:73:409.
2. Wylie EJ. Thromboendarterectomy for arteriosclerotic thrombosis of major arteries. Surgery. 1952;32:275.
3. Glagov S, Weisenberg E, Zarins CK, et al: Compensatory enlargement of human atherosclerotic coronary arteries. N Engl J Med. 1987;316:1371.
4. Ho GH, van Buren PA, Moll FL, et al. Incidence, time-of-onset, and anatomical distribution of recurrent stenoses after remote endarterectomy in superficial femoral artery occlusive disease. J Vasc Surg. 1999;30:106-113.
5. Teijink JA, van den Berg JC, Moll FL. A minimally invasive technique in occlusive disease of the superficial femoral artery: remote endarterectomy using the MollRing Cutter. Ann Vasc Surg. 2001;15:594-598.
6. Rosenthal D, Schubart PJ, Kinney EV, et al. Remote superficial femoral artery endarterectomy: multicenter medium-term results. J Vasc Surg. 2001;34:428-432.