Results of Modified Profundoplasty and Femoral Bifurcation Reconstruction with Suture-free Common Femoral Artery

The role of profundoplasty is well-established as central for patients affected by chronic limb-threatening ischemia (CLTI) and, in selected cases, for patients with disabling intermittent claudication. The most largely adopted technique involves endarterectomy of the common femoral artery (CFA) and of the profunda femoris artery (PFA) followed by surgical reconstruction through the interposition of a patch, which can be synthetic or biological. Although widely used, this technique is not without pitfalls related to the use of synthetic material, the primary concern being the risk of infection associated with it. The aim of this study is to describe the outcomes of our alternative approach to traditional profundoplasty, which represents the standard of care at our institution and may offer relevant advantages in comparison to the usual approach.

From July 2017 to February 2025, 69 consecutive patients (mean age 69.2 years, range 61-86 years) underwent an alternative approach to profundoplasty requiring superficial femoral artery (SFA) transection, medial longitudinal PFA incision, retrograde CFA endarterectomy, and standard PFA endarterectomy with optimal management of the distal endpoint). Proximal SFA is always reattached to reconstruct the PFA. In particular, depending on clinical factors, such as the presence of CLTI, or anatomical factors, such as the presence of a nonrevascularizable occlusive disease of the SFA, it can be either used as autologous patch (terminalized SFA) or sutured back, effectively "lowering" the femoral bifurcation. Clinical outcomes were assessed at 6, 12, 24, and 36 months. The primary endpoint included technical success, primary patency, and secondary patency. Secondary endpoint considered major limb amputation, primary-assisted patency, and all-cause mortality.

Of 69 patients, 28 (40.5%) were Rutherford 3 (severe claudication), 33 (47.8%) Rutherford 4 (CLTI, with rest pain), and 8 (11.7%) Rutherford 5 (CLTI with presence of trophic lesions). The CFA was involved in 95.6% and the PFA in 92.7% of cases. Concomitant iliac disease was present in 20.2% and significant external iliac artery or SFA pathology in 52.1% and 49.2%, respectively. Multilevel disease predominated (75.4%). Technical success was 100%. After endarterectomy, the SFA was either sutured back and lowered (56.5%) or terminalized for patching (43.5%). Concomitant inflow procedures were performed in 55% and outflow procedures in 17.3% patients. Mean ankle-brachial index improved from 0.45 to 0.68. Thirty-day mortality and major amputation were 0%; local and systemic complications were 5.8% and 1.4%, respectively. At mean follow-up of 53.4 months, primary, primary-assisted, and secondary patency at 2 years were 93.8%, 96.9%, and 100%, with 96.7% limb salvage and 83.1% survival.

In our experience, this technique is a valid alternative to the typical profundoplasty, with the potential advantages being a suture-free CFA, leaving an intact potential site of puncture for future endovascular approach, and the absence of synthetic material in the groin, with consequent reduced risk of infective sequelae and costs.