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Endarterectomy for CFA Disease: Indications, Techniques & Risk Reduction
Sophie Frankenthal • Updated Jan 5, 2025 • 36 hits
Common femoral artery (CFA) disease poses a distinct challenge in vascular surgery due to its complex anatomy and critical role in maintaining lower extremity circulation. Severe CFA stenosis can disrupt blood flow to peripheral arteries, jeopardizing limb perfusion and overall vascular health. While both endovascular and open surgical treatments are available, the unique demands of CFA disease often make endarterectomy – the surgical removal of plaque – the most effective solution for restoring arterial patency.
Vascular surgeon Dr. Mazin Foteh explains the key indications for performing CFA endarterectomy, outlines surgical techniques to enhance arterial clearance, and covers strategies for minimizing postoperative complications. These approaches aim to achieve durable results and improve patient outcomes.
This article features excerpts from the BackTable Podcast. You can listen to the full episode below.
The BackTable Brief
• Chronic CFA disease predominantly affects younger, heavy smokers. It is characterized by calcified plaque formations that can critically narrow the arterial lumen, often requiring surgical intervention.
• Intervention is critical in cases where severe CFA stenosis compromises profunda femoris artery patency, inflow for bypass grafts, or SFA stents. Isolated common femoral endarterectomy can often resolve claudication without treating downstream lesions.
• A longitudinal incision, extended endarterectomy into adjacent arteries, thorough branch dissection, and patching are key techniques to ensure complete disease removal and minimize the chance of restenosis.
• Endarterectomy carries significant risks, including complications like lymphoceles and hematomas, as well as a 15% readmission rate. Techniques such as proper patching, tissue plane management, and preservation of the media layer can reduce complications.
Table of Contents
(1) Evaluating CFA Disease
(2) When to Treat CFA Disease with Endarterectomy
(3) CFA Endarterectomy Surgical Pearls
(4) Preventing Complications in CFA Endarterectomy
Evaluating CFA Disease
CFA lesions typically span 5-6 cm and are distinguished by calcified plaque formations that can be either homogeneous or heterogeneous in nature. These plaques are composed of layered calcium, lipid, and platelet deposits encased in fibrin. As the plaque burden increases, luminal narrowing becomes significant, with severe cases reducing the arterial diameter to as little as 1-2 mm, critically impairing blood flow and arterial patency.
Accurate assessment of CFA lesions poses a challenge, as imaging modalities such as ultrasound and CT often underestimate the disease’s severity. The full extent of the disease is often revealed only during intraoperative evaluation. Despite these challenges, CFA endarterectomy remains a highly effective treatment option, especially for younger patients with isolated disease. The procedure delivers durable outcomes with excellent long-term patency rates and minimal need for re-intervention.
[Dr. Sabeen Dhand]
Let's get at it. Acute common femoral disease. We're not even going to talk about, we know, all of us have been there, closure device injury or some hydrogenic injury, that's surgical. As far as the technique, we'll cover, but we're going to be talking about chronic disease. What type of patients, Mazin, do you see get pretty bad chronic common femoral disease? Is it the diabetics? Are it the smokers? Is there any type of pattern?
[Dr. Mazin Foteh]
Yes, I think there are some patterns here. Let's take out of the picture the folks who have had multiple access points in their common femoral arteries, and let's just focus on primary atherosclerosis and who presents with common femoral disease. Truly, it's smokers. Those are the folks who are going to get aortoiliac occlusive disease and common femoral disease.
On occasion, you might encounter your diabetics or your end-stage renal patients who have some common femoral disease, but in general, those folks are going to be free from atherosclerotic plaque and the common femoral distribution. It's usually younger patients, it's usually heavy smokers, and they typically get dense calcific disease in the common femoral artery. Those are the folks that we are commonly approaching.
[Dr. Sabeen Dhand]
Yes, that's what I was going to ask you. What's the morphology? Is it usually calcified? Is it atheromatous? What do you most commonly encounter in these smokers?
[Dr. Mazin Foteh]
Yes, so generally, less atheromatous and more calcified homogenous plaque or heterogeneous plaque in the common femoral artery. Typically speaking, when you open these vessels up to do an endarterectomy, you're not going to see the cauliflower appearance, dense calcified disease. It's usually layers and layers of calcium and lipid deposits and platelet deposits encased in a fibrin sheet.
Over time, as that lipid deposit and platelet deposit increases, luminal patency and luminal diameter tends to decrease over time. When we do endarterectomies, when it's completed, we have this nice, five to six centimeter long lesion. If you turned it on end and looked straight down the center, you got one to two millimeters of flow, typically speaking. Removing it, particularly in young patients, works really well.
As you know, the beauty of that is it's a pretty durable operation. Thinking back in the last 10 years, I actually can't think of a patient where I've had to go back and do a repeat intervention on a common femoral for a young patient as long as it was done well. I know it does happen, but nothing directly comes to mind. To get back to your question, it's just a different animal. It's not like what you see in tibial disease and it's certainly not what you see in the SFA. It's just a completely different animal.
[Dr. Sabeen Dhand]
Yes. No, I'm always amazed. As endovascular guys, we're so used to seeing what it looks like on ultrasound or maybe IVUS or CT, and I always get amazed. Just this last week, we did a cut-down approach for an EVAR with our vascular surgeon, and the common femorals, they were just so jacked. It was just so amazing to see what the artery-- It just looked like an artery, looked a little irregular. You can touch it and it just feels-- It doesn't feel like a rock. It just feels like this really firm vessel that's not normal. It's amazing to see it physically. It's way different than what you'd expect.
[Dr. Mazin Foteh]
Absolutely. Unfortunately, I think ultrasounds and CT scans sometimes are just really great suggestions. To your point, I was doing a case yesterday, actually, an EVAR on a patient, and we did it percutaneously. I was a little bit worried about the right side. Before continuing with the EVAR, I went up and over and took some pictures and I found a big 90% stenosis below my access point. I did all the right things. I went ahead and crossed it from the other side. I removed my sheath, I ballooned it, I took a picture after the sheath went back in and it looked beautiful…
Interestingly, when I do my EVARs, I always do them with [unintelligible 00:13:44], and within minutes of pulling the sheath, the tech reached out and said, "Hey, Dr. Foteh, I'm losing signals here." I immediately cut down, and God, it was just such a horrible vessel that you would have never appreciated on CT or ultrasound. Yes. It can definitely hide some snake within those thick walls. Yes.
[Dr. Sabeen Dhand]
Yes. Now, there's something we would do-- We'd almost see drive-by common femoral disease. Meaning, the patient has multi-station disease, SFA disease, tibial disease, those common femoral disease. A lot of times we just pass by it, endovascular, and treat the SFA and tibial, and we just see, "Okay, let's see if we even have to treat the CFA disease."
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When to Treat CFA Disease with Endarterectomy
Determining when to treat CFA disease requires careful evaluation of its role in general limb perfusion. CFA intervention is necessary in cases of severe stenosis compromising profunda femoris artery patency, required inflow for distal bypass grafts, or persistent high-grade CFA lesions following iliac stenting or external iliac artery ballooning. Such stenosis can also impair the patency of superficial femoral artery (SFA) stents by limiting inflow.
Isolated CFA endarterectomy plays an important role in managing these cases, often resolving claudication in patients with multilevel disease and eliminating the need for treating downstream lesions such as SFA or tibial lesions. Although there is a growing trend toward radial or tibial access strategies, it is vital not to neglect significant CFA disease during these shifts, as untreated lesions can lead to poor outcomes in the management of multilevel vascular disease.
[Dr. Sabeen Dhand]
The question I'm getting at here is, when do you have to treat common femoral disease? Because sometimes you treat all that and the patient gets better
.
[Dr. Mazin Foteh]
Yes, no, I've been there too myself. Oftentimes, for instance, if you have a tight iliac or a SFA occlusion, and even in the setting of common femoral disease, and you leave the common femoral alone, most people are going to be fine. I think where it's really critical for us to treat the common femoral are several scenarios. These are the ones that are coming immediately to mind. If at any point the profunda femoris artery is going to be compromised or is prone to being compromised because the common femoral disease is so significant, to me, it oftentimes means I should preemptively try to treat that common femoral.
If there is a bypass graft below the common femoral that is necessitating inflow, that's somebody, I think, that should be treated. If there's an SFA dent that you're worried potentially has the ability to go down if you don't treat it, I would definitely think about doing it as well. Then on the flip side, in the superior disease, if you do stent the iliacs or if you balloon the external, but you leave a 90% common femoral stenosis, that's not going to do anybody any good. It tends to be an underappreciated artery.
There have been many scenarios where the operation I will offer is just a common femoral artery endarterectomy in somebody who has multi-level disease. More often than not, especially for claudicants, that's what gets them better. You don't have to treat the SFA and you don't have to treat the tibials and they can go on and have productive lives. It's just something you should really focus on and take some time appreciating.
Now everybody's trying to switch their access points, going to tibial, going to radial, forgetting about the common femoral artery. There's this saying, I think it was Julius Caesar or one of those Roman kings, that, "Don't forget your dying king." The truth is, the common femoral artery, we should respect it. We've been using it for such a long time and we shouldn't let it go by the wayside, but we also need to understand you can't leave a lot of bad disease in there, it's going to pretend a bad outcome.
CFA Endarterectomy Surgical Pearls
Successful CFA endarterectomy requires complete clearance of diseased segments. A longitudinal incision is preferred over a medial groin crease incision, as it provides superior exposure and visualization. The endarterectomy should extend 3-4 cm into both the proximal superficial femoral artery (SFA) and the profunda femoris artery, with thorough dissection of secondary and tertiary branches to ensure complete disease removal. When the external iliac artery is inaccessible surgically, placing an external iliac stent may be considered to prevent the occurrence of residual disease.
Dr. Foteh emphasizes the importance of patching the artery after endarterectomy to minimize the risk of restenosis. In cases involving extended dissections, multiple patches can be sewn together to ensure robust repair. This technique eliminates residual disease or dissection planes, optimizing outcomes and enhancing long-term patient satisfaction.
[Dr. Sabeen Dhand]
What about in your technique, and we won't go into in all techniques of what do you exactly do, but do you do anything other differently? You mentioned that you patch all of yours and you go to the media, but anything else you particularly do that makes your endarterectomy approach pretty successful?
[Dr. Mazin Foteh]
Yes. First off, you're going to run into surgeons out there who like to either do a longitudinal incision versus a medial groin crease incision. Really, for an endarterectomy, I think a medial groin incision doesn't really allow you to expose everything very nicely. I always do it longitudinally. I always go out very far on the secondary and tertiary branches of the profunda femoris. I always go about 3cm or 4cm into the SFA with my endarterectomy, and I never leave anything behind in the external iliac.
In fact, if I'm not able to reach it from my surgical approach, that patient more often than not is going to get an external iliac stent, just to ensure I leave no disease behind. Taking that extra time and ensuring that 3cm to 4cm proximal and 3cm to 4cm distal to your common femoral, the arteries are nice and clean, you're not leaving dissection planes behind, is key to really having a great outcome for those folks.
[Dr. Sabeen Dhand]
Yes, I can see now why you have such a good endarterectomy result, because you're definitely putting more into it than I've seen, doing the proximal 3cm of SFA. That's a lot more dissection. I've been there in these cases, where the vascular surgeon is dissecting, and yes, you can do a lot more, but it takes a lot more time.
[Dr. Mazin Foteh]
Definitely.
[Dr. Sabeen Dhand]
Dissecting three branches of the profunda, that's a lot.
[Dr. Mazin Foteh]
It gets to be a lot, but truthfully, even if you have to use two patches and sew them together, it's the right thing to do. It improves outcomes, and the patients will love you for it, is what I can tell you.
Preventing Complications in CFA Endarterectomy
CFA endarterectomy, while often considered a straightforward procedure, carries significant risks, including a 15% readmission rate and up to 30% complication rates. Common complicates include lymphoceles, groin wound breakdown, hematoma formation, chronic pain, and, though rare, perioperative mortality. These risks emphasize the need for proper patient selection, surgical technique, and thorough patient counseling
Several surgical techniques can minimize the risk for patient complications and restenosis. These include the careful patching of the artery after endarterectomy and precise tissue plane management during plaque removal. Preserving the media layer is vital to prevent a hyperplastic tissue bed. In cases of severe calcific disease, where distinguishing planes becomes challenging, an iliofemoral bypass may provide a safer alternative.
[Dr. Sabeen Dhand]
The endarterectomy, the surgical approach to common femoral disease, you've already mentioned that durability. it's by far very durable. I know it hasn't happened to you, but what are things that do make it, you have a recurrent disease in the patch or whatnot? What are some things that can cause that?
[Dr. Mazin Foteh]
Yes. There's a number of things. One thing you mentioned is the patch. There are still people out there who don't patch common femorals after doing endarterectomy. It's similar to doing CEA. There are still people out there who just do endarterectomy and then primarily close the carotid artery. If you don't patch it, I think that puts you at risk for restenosis. There's also a subset of patients who I think have inflammatory atherosclerotic disease. Those folks, they tend to scar no matter what you do. Despite doing a clean endarterectomy and not leaving-
[Dr. Sabeen Dhand]
They'll scar.
[Dr. Mazin Foteh]
They'll scar down and you'll be back. Then I think the other thing is when you're doing your endarterectomy, it's important to leave some of the media behind when you're getting into the layers to remove the plaque. If you take it all the way down to the adventitia and you remove all of the media, I think that leaves a very, very hyperplastic tissue bed and puts you at risk for restenosis. It's important to make sure you stay in the right tissue planes as well.
[Dr. Sabeen Dhand]
How hard is that to do, to separate, when you're there, the intima versus media versus adventitia? Are you able to actually tell the different layers?
[Dr. Mazin Foteh]
Generally, yes. Generally, you're able to get into a well-defined plane and it works out well for you to be able to do that. There are scenarios where the disease is so bad or it's exophytic calcium that embeds itself, even into the adventitia, that you just simply can't make a good tissue plane. Those are the folks that I think that instead of patching, you end up doing iliofemoral bypasses as opposed to doing endarterectomies.
It's an operation, I think, that doesn't get a lot of credit. People think it's just so easy to do and the recovery is so easy, but I think we also underestimate the complications that occur with that surgery. There was a huge NISQIP paper that came out back in 2008 looking at 75,000 endarterectomies that were done over a 10-year period. The readmission rate for that procedure was 15%, the complication rates were as high as 20% to 30%.
Typically speaking, these patients, pretty routinely will come back either with lymphoceles, they'll come back with groin incisions that are broken down, they'll come back with hematomas, chronic pain, and readmissions [crosstalk] hospital.
[Dr. Sabeen Dhand]
It's not [crosstalk] it's not completely-- [crosstalk]
[Dr. Mazin Foteh]
No, not by any means. In fact, that paper, actually, that population did have a mortality rate, a perioperative mortality rate of about 1% to 2%. Although rare, it's not without its complications.
[Dr. Sabeen Dhand]
Yes, absolutely. 75,000 is a big number, so you're going to find stuff. It's important to know that these type of procedures, that they're not as easy as sometimes some people may say they are.
Podcast Contributors
Dr. Mazin Foteh
Dr. Mazin Foteh is a practicing vascular surgeon in Austin, Texas.
Dr. Sabeen Dhand
Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.
Cite This Podcast
BackTable, LLC (Producer). (2022, January 24). Ep. 181 – Surgical vs. Endovascular Management of CFA Disease [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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