The Role of Surgery in the Treatment of PAD
Richard Neville, MD, FACSAssociate Director, Inova Heart and Vascular Institute
Vice-Chairman, Department of Surgery System Chief of Vascular Services
Inova Health SystemFalls Church, Virginia
Faculty Disclosures
Richard Neville, MD, FACS: Consultant – Graftworx, W.L. Gore; Grant/Research Support – Medtronic, W.L. Gore; Scientific Advisory Board – Graftworx, Tissue Analytics, W.L. Gore
Brand names are included in this presentation for participant clarification purposes only. No product promotion should be inferred.
Role of Surgery in today’s PAD practice• Surgical bypass
– Femoral-popliteal bypass rarely– Femoral - Tibial bypass
• Iliofemoral thromboendarterectomy (femoral bifurcation disease)• Hybrid surgical revascularization (inflow and outflow revascularization)• Failed endovascular intervention• Innovations have occurred in surgical therapy
– Distal Vein Patch for prosthetic bypass– Heparin bonded grafts and patches– Deep venous arterialization for lack of distal arterial targets– Remote monitoring technologies
Symptoms: Claudication
• Pain– Reproducible– Functional muscle– Relieved by rest
• Significance– 75% stable– 10% amputation (increased with DM, tobacco)– Mortality – 30%
• Surgery rare for claudication
Emperor Claudius (AD 54) Claudicare – to limp
Symptoms: Limb threatening (CLTI)
• Rest Pain– Distal foot/toes– Unilateral– Burning at night – can’t sleep– Dependent rubor
• Tissue loss– Non-healing ulcer– Gangrene
• Surgery for 25%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
VQI Centers Mean = 31% bypass
National pattern of LE revascularization
100% Endo
100% Bypass
VQI Centers
Surgical Bypass as first therapy
• Patient– Reasonable life expectancy and level of function
• Indication for revascularization – Significant tissue loss (> 2cm)
• Arterial anatomy – Long segment (tibial) occlusions– Common femoral artery disease
• Failed endovascular therapy
Bypass as the initial option for PAD
• Survey of endovascular surgeons• Indications for a bypass first approach to PAD
• Common femoral artery pathology
• Extensive foot gangrene/sepsis
• Young patients and those requiring soft tissue reconstructions where durability is paramount
• Long, infrageniculate occlusion with a single, distal tibial target vessel.
Lawrence PF, Chadra A, Eur J Vasc Endovasc Surg (2010) 39, S32eS37
Arteriography important to plan surgical therapy
• Distal tibial occlusive disease• Limb Center– 533 initial diagnostic– 276 primary interventions
Technique for bypass• Inflow artery• Outflow artery• Conduit– Large saphenous– Small saphenous– Arm vein– Prosthetic• ePTFE• Dacron
– Cryopreserved vein
But, surgical bypass has changed…..
J Vasc Surg 2000;31S:192-274
And, bypasses are more challenging……
• Absence of saphenous vein– 30% in CLI practice– 50% after failed prior bypass
• Poor quality vein• No good target artery for the bypass
Prosthetic graft failure
• Technical first month• Hyperplasia 6 to 24 months• Atherosclerosis beyond 24 months
Improved prosthetic graft performanceDistal Vein Patch
Neville , et al. Am J Surg 1997;174:173-6.
Improve prosthetic graft performanceHeparin-bonded ePTFE
Reduce platelet deposition
Reduce thrombus formationReduce myointimal hyperplasia
Heyligers, et al. J Vasc Surg. 2006;43:587-591. Lin, et al. J Surg Res. 2004;118:45-52.
Distal Vein Patch bypass
Minimal incisionsLength not an issue
HePTFE vs Saphenous vein for tibial bypass
Neville RF, et al. J Vasc Surg. 2012;54(4):1008-1014.
Primary Patency
Conduit length not an issueIliac to contralateral AT
DVP bypass with common-ostium dAVF
DVP bypass with Deep Venous Arterialization
Femoral bifurcation disease
• Endarterectomy has been the gold standard for atherosclerotic disease of the CFA.• Endarterectomy alone may be sufficient for patients with disabling claudication • Those with tissue loss and more extensive lesions likely require additional
revascularization (hybrid procedure)
CFA endarterectomy: TechniqueIncisions Endarterectomy Tack endpoint Patch closure
Iliofemoral endarterectomy
Ilio-femoral endarterectomyFollow up arteriogram – 8 monthsPatch intact, no restenosis
Complications after CFA endarterectomy• 1843 patients (NSQIP, 2005-2010)• Indication
– Claudication 64% – CLI 36%
• Mortality 3%• Morbidity 11%
– Superficial infection 6%, – Deep infection 2%– Dehiscence 0.8%
• Independent predictors of morbidity• Obesity• Steroid dependence
Nguyen BN, Neville RF, et al. J Vasc Surg 2015;61(6):1489-91
Hybrid procedures CFA endarterectomy with endovascular Rx
• Femoral endarterectomy with proximal/distal endovascular revascularization• Multilevel revascularization through one point• Iliac endovascular interventions possible• Femoral-popliteal-tibial interventions possible• Decrease in morbidity and length of stay
Doslouglu H Vasc Endovasc Surg Sharafuddin MJ Vasc Endovasc Surg Chang RW J Vasc Surg.
Amputation: one of the first procedures in surgical history
Ambrose Pare (16th Century)
Pecoraro RE, Reiber GE Pathways to limb amputation. Basis for prevention. Diabetes Care. 13.
Primary amputation: May be the right choice
• Non-ambulatory• Dementia• Faulty wound healing: 14% • Gangrene: 40% • Infection: 41%
• 50% not due to a vascular cause
Amputation principles
Lisfranc
Chopart’s
Symes
• Optimal biomechanics• Maximize viable tissue• No pressure points• Early ambulation
Below knee amputation: Design is key
“Life altering, not life ending”
Role of Surgery in today’s PAD practice• Surgical bypass
– Femoral-popliteal bypass rarely– Femoral - Tibial bypass
• Iliofemoral thromboendarterectomy (femoral bifurcation disease)• Hybrid surgical revascularization (inflow and outflow revascularization)• Failed endovascular intervention• Innovations have occurred in surgical therapy
– Distal Vein Patch for prosthetic bypass– Heparin bonded grafts and patches– Deep venous arterialization for lack of distal arterial targets– Remote monitoring technologies
