Patients and methods: The single-center observational study included 48 consecutive patients (46 males, 2 females; mean age: 60.0±6.1 years; range, 48 to 73 years) who underwent RE (n=24) or FPB surgery (n=24), which was performed solely for peripheral artery disease, between January 2017 and January 2022. Demographic and clinical data of the patients and data related to the procedures and follow-up were obtained from hospital records, and the evaluations were performed retrospectively. The exclusion criteria were defined as being under 18 years of age and undergoing FPB following trauma.

Results: While 21 (87.5%) of the patients who underwent RE had a lesion in the popliteal artery, none of the patients who underwent FPB had a popliteal artery lesion. The one-year patency rate in patients who underwent RE and FPB was 73.9% and 62.5%, respectively. Although the Global Limb Anatomical Staging System scores of patients who underwent RE were more advanced, patency rates were found to be higher. The number of patients who underwent RE and required revascularization within the first week was five (21.7%), and all of these procedures were performed endovascularly. In the FPB group, the number of patients requiring revascularization was two (8.3%), and embolectomy was performed in these patients.

Conclusion: Remote endarterectomy may be a good option in patients who have long-segment lesions, in those who previously underwent FPB surgery, in patients who require repeated intragraft embolectomy revisions, in those with limited access for endovascular procedures, in patients with graft infections, and in those who cannot use prosthetic materials.

Remote endarterectomy, originally developed as a less invasive alternative to femoral-popliteal bypass (FPB) surgery, allows for the removal of the atherosclerotic plaque and restoration of blood flow through a small incision in a remote location of the artery. Nowadays, the role of endovascular interventional methods increases in the treatment of SFA stenosis or occlusion.[3] The segment most commonly treated with endovascular interventions is the femoropopliteal arterial segment.[4] As researchers and clinicians seek to refine and expand the scope of RE, it is vital to examine the effectiveness of this procedure in addressing SFA occlusions and its potential benefits over alternative treatment options.

This study aimed to explore the current state of knowledge regarding RE in the context of SFA occlusion. By examining existing research, clinical outcomes, and patient experience, we endeavored to assess the efficacy of RE as a treatment modality for this challenging condition. This exploration sought to determine whether RE represents a promising avenue for improving outcomes in individuals suffering from SFA occlusion, potentially offering enhanced symptom relief, increased quality of life, and improved long-term vascular health.

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.

Table 1: Demographic and clinical characteristics by type of operation

All patients included in the study had long-segment SFA lesions and were classified with the femoropopliteal Global Limb Anatomical Staging System (GLASS). According to GLASS scores, 18 (75%) patients who underwent RE were evaluated as Stage 3, and six (25%) were evaluated as Stage 4. Among patients who underwent FPB surgery, 20 (83.3%) were evaluated as Stage 2, and four (16.7%) were evaluated as Stage 3 (Table 2). There was also a statistically significant difference in lesion lengths according to the type of surgery (p<0.05). Lesions in RE were found to be longer than lesions in FPB surgery (Table 3).

Table 2: Staging according to the type of operation

Table 3: Comparison of mean lesion lengths according to operation type

In the RE and FPB groups respectively, according to the Rutherford category, nine (37.5%) and four (16.7%) patients had mild claudication, six (25%) and nine (37.5%) patients had moderate claudication, five (20.8%) and six (25%) patients had severe claudication, and three (12.5%) and five (20.8%) patients had rest pain. There was only one (4.2%) patient with minor tissue loss in the RE group.

Procedural success was achieved in 95.8% and 100% of cases in the RE and FPB groups, respectively. Among the patients who underwent RE and required revascularization within the first week, five (21.7%) underwent endovascular procedures. Two (8.3%) of patients who underwent FPB and required revascularization underwent embolectomy procedures.

Dacron grafts were used in four (16.7%) patients who underwent RE, and SVG patches were used in 11 (45.8%). In this group, arterial integrity was achieved in eight (33.3%) patients using the primary closure method, while PTFE interposition was used in one (4.2%) patient (Table 1). No wound infection was reported.

In our study, it was found that RE was most frequent procedure when the additional lesion areas were PFA, CFA, and EIA (p<0.05). Lesion length was found to be longer in RE compared to FPB surgery (p<0.05; Table 3).

When the one-year patency of all patients was examined, 32 (68.1%) were found to have patent arteries. Postdischarge follow-ups for these patients were conducted using DUS in 27 (56.2%) and CTA in 21 (43.8%) (Additional Table 1). The mean preoperative ankle-brachial index was 0.49±0.10, and the mean postoperative ankle-brachial index was 0.86±0.08 (Table 4). The relationship between preoperative and postoperative ABI values and patency is also illustrated in Additional Table 2.

Table 4: Variables related to operations

A statistically significant relationship was found between the patency status observed one year after surgery and the type of medication at discharge (p<0.05). When the data was examined, it was observed that all patients discharged with VKAs had patent grafts (p<0.05). While VKA was mostly prescribed to patients who underwent RE at discharge, clopidogrel was mostly given to patients who underwent FPB surgery (p>0.05) (Table 5).

Table 5: Associations and cross-tabulation between patency status at one-year and demographic and clinical characteristics for all patients

When the relationship between the one-year patency of FPB patients and preoperative creatinine values was examined, it was observed that the graft was mostly occluded in patients with renal dysfunction (p<0.05). All patients were evaluated, and no significant relationship was found between renal dysfunction and one-year patency.

Diabetes mellitus is a well-known factor that may affect the success rates of surgical procedures.[5] Statistically significant relationships were not obtained between diabetes mellitus, sex, age, surgical side, hypertension status, smoking, one-year patency rate, and the type of surgery (p>0.05).

Remote endarterectomy is a good choice in long segment lesions, where the success rate of endovascular intervention is low, in redo patients who previously underwent FPB surgery, and in patients with graft infection.

The contributions of RE to the medical literature include offering a minimally invasive approach that accelerates recovery and reduces the risk of complications.[7] This technique results in reduced pain and faster recovery compared to open surgical methods, leading to shorter hospital stays. Additionally, studies on the long-term outcomes of RE provide valuable data for clinical applications.[8] Overall, these contributions enhance the understanding of this technique for both surgeons and patients, further enriching the clinical knowledge base.

As a result of examining the one-year primary patency rates, when the GLASS stage of the patients who underwent RE and FPB surgery were evaluated, although the stage of the RE group was more advanced, the one-year primary patency rate of the patients who underwent this operation was higher, which is important for the preferability of this method in suitable patients. In the study by Martin et al.,[9] it was observed that the patency rate was 70.0% at the 30-month follow-up of patients who underwent RE. In another study, it was observed that the one-year primary patency rate was 60.0%.[10] In the study by Gabrielli et al.,[11] the patency rate was found to be 76.5% at the 24-month follow-up.

In the study by Gisbertz et al.[12] comparing RE and FPB surgery, one-year patency rates were found to be 61.0% and 73.0% for RE and FPB, respectively. In our study, the one-year patency rate was 73.9% in patients who underwent RE.

Antoniou et al.[10] found the RE success rate to be 94.0% in their study. In another study, the success rate was found to be 79.0%.[13] Our success rate was 95.8%. Karathanos et al.[14] reported the technical success as 100.0% in a study of 12 patients who underwent RE. While the mortality rate was 8.0% (n=1) in the same study, no mortality was observed in our study.

Gabrielli et al.[11] reported that the prevalence of diabetes mellitus, hypertension, and smoking was 45.0%, 68.0%, and 71.0% in the RE group, respectively. In the same study, the rate of renal dysfunction, limited to an upper creatinine value of <1.5 mg/dL, was found to be 14.0%. In our study, eight RE and five FPB patients with creatinine values above the specified reference range had chronic kidney disease and did not receive preoperative dialysis. None of the patients required dialysis or progressed to chronic renal failure after the operation.

In the study conducted by Rahman and Özkısacık,[15] the one-year patency rates of patients with lower extremity peripheral artery disease who underwent endovascular procedures were reported to be similar to the rates in our study.

The study had some limitations. The individual risk factors of the patients, the lack of standardization of the discharge medication due to the medications they previously used and comorbid diseases, and the fact that the GLASS scores of the patients who underwent RE and FPB surgery were not similar were among the limitations. The inability to standardize between DUS and CTA due to patient-specific comorbidities and renal dysfunction in patient follow-up could also be considered a limitation.

In conclusion, remote endarterectomy method may be a good option in patient groups who have long segment lesions, in those who previously underwent FPB surgery, in patients who require repeated intragraft embolectomy revisions, in those with limited access for endovascular procedures, in patients with graft infections, and in those who cannot use prosthetic materials. Further randomized controlled studies with larger samples are needed to support our findings.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Idea/concept, control/supervision: B.K., B.M.; Design, writing the article, data collection and/or processing, references and fundings, other: B.K.; Analysis and/or interpretation, critical review: B.K., K.B.; Literature review, materials: B.K., S.G.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

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