Isolated Common Femoral Endarterectomy (without Infrainguinal Bypass) for the Treatment of Chronic Limb-threatening Ischemia

Occlusive disease of the common femoral artery can generate profound lower extremity ischemia as the normal collateral pathways from the profunda to the superficial femoral artery cannot adequately develop. In patients with lifestyle-limiting claudication, isolated endarterectomy of the common femoral artery (CFE) is highly effective. Because the CFE does not provide direct, in-line flow to the plantar arch, it has been felt to provide inadequate revascularization to patients with chronic limb-threatening ischemia (CLTI). The purpose of this retrospective clinical study was to test the hypothesis that select patients presenting with CLTI and common femoral arterial disease could be effectively treated with isolated CFE without concomitant infrainguinal bypass. Consecutive isolated CFE (without concomitant infrainguinal revascularization) performed in a large, urban hospital for CLTI between 2014 and 2021 were reviewed. Patient characteristics, limb, and anatomical stages using the Wound, Ischemia, foot Infection (WIfI) and Global Anatomic Staging Systems were tabulated. Long-term freedom from vascular reintervention, major limb amputation, as well as amputation-free survival were analyzed. We included 58 patients presenting with CLTI underwent isolated CFE (mean age 74 ± 10 years; 62% male, 90% current or prior smokers). Comorbidities included diabetes (52%), coronary artery disease (55%), congestive heart failure (22%), and end-stage renal failure on hemodialysis (5%). Patients presented with either rest pain (36%) or tissue loss (64%); the latter group exhibited advanced limb threat (68% in WIfI stage 3 or 4). The majority of patients had associated severe infrainguinal disease (50% Global Anatomic Staging Systems 3). CFE was well-tolerated with no 30-day mortality and a 5% incidence of cardiopulmonary complications. After a median follow-up of 17 months (range, 10-29 months), major vascular reintervention was required in only seven patients (12%). One patient (2%) required a major amputation after presentation in WIfI stage 4 (W3I3fI0). Amputation-free survival at 1 and 2 years was 81% ± 3% and 72% ± 46%, respectively (Figure). WIfI stage 4 was a significant univariate predictor of the need for subsequent open infrainguinal bypass (P = .034). Isolated CFE as primary therapy in highly selected patients with CLTI is safe and effective. Index limb stage is predictive of the need for further infrainguinal revascularization in this population.