Rounded notch method of femoral endarterectomy offers mechanical advantages in finite element models

Objective: Use of a vascular punch to produce circular heel and toe arteriotomies for femoral endarterectomy with patch angioplasty is a novel technique. This study investigated the plausibility of this approach and the mechanical advantages of the technique using finite element models. Methods: The patient underwent a standard femoral endarterectomy. Prior to patch angioplasty, a 4.2 mm coronary vascular punch was used to created proximal and distal circular arteriotomies. The idealized artery was modeled as a 9 mm cylinder with a central slit. The vertices of the slit were modeled as: a sharp V consistent with traditional linear arteriotomy, circular punched hole, and beveled punched hole. The artery was pressurized to achieve displacement consistent with the size of a common femoral artery prior to patch angioplasty. Maximum von Mises stress, area-averaged stress, and stress concentration factors were evaluated for all three models. Results: Maximum von Mises stress was 0.098 MPa with 5 mm of displacement and increased to 0.26 MPa with 10 mm of displacement. Maximum stress in the uniform circular model was 0.019 MPa and 0.018 with a beveled notch. Average stress was lowest in the circular punch model at 0.006 MP and highest in the linear V notch arteriotomy at 0.010 MPa. Stress concentration factor was significantly lower in both circular models compared with the V notch. Conclusions: Femoral endarterectomy modified with the creation of circular arteriotomies is a safe and effective surgical technique. Finite element modeling revealed reduced maximum von Mises stress and average stress at the vertices of a circular or beveled punch arteriotomy compared with a linear, V shaped arteriotomy. Reduced vertex stress may promote lower risk of restenosis.