Evaluation of femoral bifurcation endarterectomy and endovascular therapy for long tandem lesions involving the deep femoral artery

Femoral bifurcation endarterectomy (FBE) remains the gold standard for managing severe chronic limb-threatening ischemia (CLTI) involving the CFA and its bifurcation. However, limited data exists on optimal treatments for CFA lesions complicated by iliac-femoral-popliteal long tandem lesions. Historically, stenting in this region often obstructed the deep femoral artery outflow. This study assessed the feasibility of combining open endarterectomy for occluded superficial femoral artery (SFA) openings or CFA lesions with endovascular therapy (EVT) for distal segments. This study included 83 ischemic limbs from 81 patients diagnosed with occlusive arteriosclerotic disease of the lower extremities. Patients with long-segment SFA occlusive lesions involving the SFA opening and the deep femoral artery were selected. Open endarterectomy was performed at the superficial and deep femoral artery openings, followed by EVT for the distal SFA and related sites. Technical success was achieved in all 81 patients (100 %). Complications occurred in 7/81 interventions (8.6 %): brachial artery pseudoaneurysm (1), lymphatic leakage (2), wound infection (2), and distal thromboembolism (2). Ankle-brachial index (ABI) increased from 0.39 ± 0.23 to 0.96 ± 0.25 (p < .001) immediately after the intervention. Seventy patients regained dorsalis pedis arterial pulsation, and 64 recovered posterior tibial arterial pulsation. The primary patency rates at 1 month, 6 months, 12 months, 24 months, 36 months, and 48 months postoperatively were 100 %, 96.34 %, 90.24 %, 87.71 %, 86.58 %, and 86.58 %, respectively. During follow-up, 2 patients underwent minor amputation, 3 patients underwent major amputation, 11 patients developed restenosis, and 10 patients died. Restenosis was linked to occlusion length, while postoperative mortality were associated with diabetes and advanced age. FBE combined with EVT for the distal SFA is a safe and effective approach for treating CFA and iliac-femoral-popliteal long tandem lesions. It provides excellent hemodynamic improvement with favorable medium- and long-term outcomes.