Systematic Review and Proportional Meta-Analysis of Endarterectomy and Endovascular Therapy with Routine or Selective Stenting for Common Femoral Artery Atherosclerotic Disease

Abstract

Introduction. Common femoral endarterectomy (CFE) has been the therapy of choice for common femoral artery atherosclerotic disease (CFA-ASD). In the past, there was inhibition to treat CFA-ASD endovascularly with stents due to fear of stent fracture and compromise of future vascular access site. However, recent advances and new evidence suggest that CFA may no longer be a ‘stent-forbidden zone’. In the light of new evidence, we conducted a meta-analysis to determine the use of endovascular treatment for CFA-ASD and compare it with common femoral endarterectomy in the present era. Methods. Using certain MeSH terms we searched multiple databases for studies done on endovascular and surgical treatment of CFA-ASD in the last two decades. Inclusion criteria were randomized control trials, observational, prospective, or retrospective studies evaluating an endovascular treatment or CFE for CFA-ASD. For comparison, studies were grouped based on the treatment strategy used for CFA-ASD: endovascular treatment with selective stenting (EVT-SS), endovascular treatment with routine stenting (EVT-RS), or common femoral endarterectomy (CFE). Primary patency (PP), target lesion revascularization (TLR), and complications were the outcomes studied. We did proportional meta-analysis using a random-effect model due to heterogeneity among the included studies. If confidence intervals of two results do not overlap, then statistical significance is determined. Results. Twenty-eight studies met inclusion criteria (7 for EVT-RS, 8 for EVT-SS, and 13 for CFE). Total limbs involved were 2914 (306 in EVT-RS, 678 in EVT-SS, and 1930 in CFE). The pooled PP at 1 year was 84% (95% CI 75-92%) for EVT-RS, 78% (95% CI 69-85%) for EVT-SS, and 93% (95% CI 90-96%) for CFE. PP at maximum follow-up in EVT-RS was 83.7% (95% CI 74-91%) and in CFE group was 88.3% (95% CI 81-94%). The pooled target lesion revascularization (TLR) rate at one year was 8% (95% CI 4-13%) for EVT-RS, 19% (95% CI 14-23%) for EVT-SS, and 4.5% (95% CI 1-9%) for CFE. The pooled rate of local complications for EVT-RS was 5% (95% CI 2-10%), for EVT-SS was 7% (95% CI 3 to 12%), and CFE was 22% (95% CI 14-32%). Mortality at maximum follow-up in CFE group was 23.1% (95% CI 14-33%) and EVT-RS was 5.3% (95% CI 1-11%). Conclusion. EVT-RS has comparable one-year PP and TLR as CFE. CFE showed an advantage over EVT-SS for one-year PP. The complication rate is lower in EVT RS and EVT SS compared to CFE. At maximum follow-up, CFE and EVT-RS have similar PP but CFE has a higher mortality. These findings support EVT-RS as a management alternative for CFA-ASD.

Comparative Analysis of Endovascular Intervention and Endarterectomy in Patients with Femoral Artery Disease: A Systematic Review and Meta-Analysis

“…Mortality was higher for FAE (23.1%) than for ET (5.3%). These findings support that ET may be better than FAE for FAD [ 35 ].…”

“…Our review indicates a substantial advantage of safety for ET. A similar review conducted by Changal K et al [ 35 ] offered a similar conclusion. However, ET and FAE were compared with a slightly different approach.…”

Lesion Characteristics Associated with Loss of Primary Patency After Endovascular Therapy for Common Femoral Artery Lesions

“…Guidelines recommend thromboendarterectomy (TEA) as the first-line revascularization approach for common femoral artery (CFA) lesions because it achieves good long-term patency [1][2][3][4]. However, as a result of the rapid developments in endovascular techniques in recent decades, endovascular therapy (EVT) is now viewed as an alternative interventional modality for CFA lesions [5,6].…”

“…In 2017, Goue ¨ffic et al [7] reported the first randomized controlled trial (RCT) that compared TEA and CFA stenting; CFA stenting showed comparable durability and a lower complication rate than TEA. Although some reports indicate that EVT is equivalent to TEA in terms of patency, others indicate that it is still not as good as TEA [1][2][3][4]. On the other hand, EVT may be superior to TEA in terms of safety, promoting a shift from TEA to EVT [7,8].…”

Off-label use of interwoven carotid stent in common femoral artery occlusion after surgery

“…Open surgery is considered the gold standard for treatment of common femoral artery (CFA) and deep femoral artery (DFA) atherosclerotic lesions, although the role of endovascular (EV) techniques is debated. 1 , 2 , 3 We present a case of critical limb ischemia (CLI) due to total occlusion of the CFA and proximal DFA previously treated with surgical endarterectomy (EA), successfully managed with a total EV approach. The patient provided written informed consent for the report of her case details and imaging studies.…”