A total of 48 patients (46 males, 2 females;
mean age: 60.0±6.1 years; range, 48 to 73 years)
who underwent either RE (n=24) or FPB surgery
(n=24) at the Bağcılar Training and Research
Hospital, Department of Cardiovascular Surgery
between January 1, 2017, and January 1, 2022 were
included in the observational study. The exclusion
criteria were as follows: patients under the age
of 18 years and patients who underwent FPB
for revascularization following trauma. Evaluations
were conducted retrospectively. The primary
endpoint of the study was to assess the one-year
patency rate of RE. Additionally, its association
with diabetes mellitus, the lipid panel (low-density
lipoprotein, high-density lipoprotein, and total
cholesterol), smoking status, age, sex, hypertension,
and discharge medication were evaluated. In
patients who underwent femoropopliteal procedures,
saphenous vein grafts (SVGs) were never used;
PTFE (polytetrafluoroethylene) grafts were used
in all patients. The one-year patency of RE and
FPB, which was performed solely due to peripheral
artery disease, was compared. Demographic and
clinical data of patients and variables related to
the procedure and follow-up were obtained from
hospital records. The study protocol was approved by
the Bağcılar Training and Research Hospital Ethics
Committee (date: 16.11.2022, no: 2022/11/04/025).
Written informed consent was obtained from all
participants. The study was conducted in accordance
with the principles of the Declaration of Helsinki.
One-year patency was defined as the result of
computed tomography angiography (CTA) or duplex
ultrasonography (DUS) assessments performed at
the one-year follow-up for all patients. Revision was
defined as endovascular treatments and embolectomy procedures performed with the purpose of
revascularization. Restenosis was defined as stenosis
of more than 50% that did not lead to total SFA
occlusion within the first seven days postoperatively.
The target INR (international normalized ratio) for
patients prescribed a vitamin K antagonist (VKA)
at discharge was 2-3 mg/dL. Procedure success
was defined as achieving complete patency during
RE without extravasation during the operation.
Performing distal and proximal anastomoses without
complications was considered a successful FPB
surgery. Concomitant lesion was defined as lesions
classified up to less than 50% stenosis due to
extensive calcification in the External iliac artery
(EIA), common femoral artery (CFA), profunda
femoral artery (PFA), or popliteal artery (PopA) that
did not lead total occlusion. Additional surgery was
defined as revision operations performed in case of
restenosis, hematoma development, or bleeding using
endovascular or open surgical methods. Values above
the reference range of 1.00 mg /dL, determined by
the central laboratory for creatinine levels, were
classified as renal dysfunction.
Surgical procedure
Remote endarterectomy is generally performed
in hybrid operating rooms; however, we conducted
the procedure in the angiography unit within our
available resources. An incision was made in the
femoral region on the lesion side of the patient.
After turning the CFA, SFA, and PFA with tapes,
it was ensured that an adequate field of view was
obtained, and heparinization was performed with
heparin sodium administered at 5,000 IU. The
activated clotting time (ACT) measurement was
performed to achieve a target value >200.
After making an arteriotomy with a longitudinal
incision of approximately 5 cm, the plaque was
visualized, freed, and completely cut vertically
from the middle. Endarterectomy was performed
on both arteriotomy sites. A Martin dissector
(LeMaitre, Burlington, USA) was passed around the
plaque. The plaque was dissected from all sides of
the vessel, and then using a Vollmar ring dissector
(LeMaitre, Burlington, USA), the plaque was
completely freed up to the area where preoperative
measurements were taken and marked. Subsequently,
the most distal part of the measured and freed region
was cut using a MollRing cutting transection device
(LeMaitre, Burlington, USA), and the plaque was removed in one piece. Immediately afterward, a 6F
sheath was stabilized from the arteriotomy site, and
imaging was performed using digital subtraction
angiography. The residual lesion remaining in the
distal SFA region was retrieved using the EndoHelix
Retrieval device (LeMaitre, Burlington, USA). After
the residual lesion was removed, another digital
subtraction angiography image was taken, and if focal
stenotic foci were observed, balloon angioplasty was
performed as needed.
In cases where complete patency was achieved
without any complications, the arteriotomy site
was closed by primary closure, with a Dacron graft
or SVG depending on the diameter of the artery,
using 5-0 sutures. Following hemostasis control, one
Hemovac drain was inserted, and the procedure was
successfully concluded.
Postdischarge medication
All patients received low-molecular-weight
heparin (LMWH) after discharge. Nineteen
patients who underwent RE were discharged
with LMWH, acetylsalicylic acid (ASA), and
VKA, while three patients were given clopidogrel
treatment instead of VKA. Two patients were
discharged with only LMWH and ASA due to the
risk of bleeding.
In the group that underwent FPB, 16 patients
were given LMWH, ASA, and clopidogrel, while
six patients were given VKA instead of clopidogrel.
Two patients were discharged with only LMWH and
ASA due to the risk of bleeding.
When deciding on medication after discharge,
parameters such as the antithrombotic and
anticoagulant drugs used by patients before the
operation, the presence of coronary artery and carotid
artery diseases, atrial fibrillation, and comorbidities
were evaluated.
Statistical analysis
Data were analyzed using IBM SPSS version
25.0 software (IBM Corp., Armonk, NY, USA).
Descriptive statistics (number, percentage,
mean ± standard deviation (SD), minimum, and
maximum) of the data were provided in the study.
As the first step in data analysis, the normality
assumption was checked with the Shapiro-Wilk
test. When the normality assumption was met,
the independent sample t-test was used to examine the difference in means of two independent
groups, and when the assumption was not met,
the Mann-Whitney U test was conducted. In cases
where the normality assumption was met, a paired
t-test was used to examine the difference in means
of two dependent groups, and in cases where the
assumption was not met, the Wilcoxon signed-rank
test was used. A p-value <0.05 was considered
statistically significant.