FEMORAL ARTERY ENDARTERECTOMY
Femoral artery endarterectomy is a surgical procedure used to remove atherosclerotic plaque material, or blockage, from the femoral artery. The femoral artery, one of the major arteries of the leg, can become blocked due to peripheral artery disease (PAD), often as a result of atherosclerosis.
Here is a general description of the procedure:
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Incision: The surgeon makes an incision in the groin to expose the femoral artery.
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Clamping: The femoral artery is clamped above and below the blockage to prevent blood flow during the procedure.
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Arteriotomy: The surgeon makes an incision (arteriotomy) directly into the artery at the site of the blockage.
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Endarterectomy: The surgeon carefully removes the plaque from the artery using special surgical instruments.
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Artery Repair: After the plaque has been removed, the artery is repaired. This can be done by sewing it directly or by using a patch graft (using a piece of another vein or synthetic material).
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Flow Restoration: The clamps are removed, restoring blood flow through the artery.
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Closure: The surgeon closes the incision.
Anesthetic Implications for Femoral Artery Endarterectomy
Anesthesia type: General, regional
Airway: Endotracheal tube
Preoperative:
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Patients normally have significant peripheral arterial disease (PAD)
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Patients may have multiple comorbidities such as diabetes, coronary artery, renal, or respiratory disease
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Poor exercise tolerance (<4 METS) is associated with an increase in perioperative myocardial ischaemia and cardiac events
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Diabetic control must be optimized before surgery
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An arterial line is required for frequent ACT draws and blood pressure management
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Have heparin and protamine available
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Protamine use may result in an unwanted allergic-type reaction
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Urinary catheter inserted to monitor urine output
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The “five P’s” of acute peripheral vascular disease (PVD) symptoms are pain, paralysis, paresthesia, pulselessness, and pallor
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Type and cross-match the patient preoperatively
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Consider having blood units available
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Coronary artery disease (CAD) is the leading cause of perioperative mortality during vascular surgery
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Maintain cardiovascular stability during induction, laryngoscopy, intubation and extubation
Intraoperative:
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Position: Supine with arms tucked
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Muscle relaxation is usually required
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Tachycardia should be avoided perioperatively as it increases myocardial oxygen demand while decreasing myocardial perfusion
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Maintain blood pressure within 20% of the patient's baseline
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Heparin is administered before the clamping of arteries
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Reperfusion of an ischaemic limb after a prolonged period of clamping may cause transient hypotension
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Maintaining normothermia is crucial
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Hypothermia causes vasoconstriction
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Shivering increases oxygen requirements
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Aggressively replace blood loss with crystalloids, colloids, and blood products as needed
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Maintain oxygenation and ventilation guided by blood gas analysis
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Intraoperative glucose control
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Hyperglycemia can cause hypovolemia, electrolyte abnormalities, and increased surgical site infections
Postoperative:
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Avoid hypertension with emergence as it may challenge the new graft and incision
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Pain management
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Monitor metabolic disturbances
Complications:
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Groin hematoma
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Bleeding
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Stroke
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Cardiorespiratory complications
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Washout of free radicals
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Pseudoaneurysm
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Compartment syndrome
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Reperfusion injury following revascularization (hyperkalaemia, cardiac arrhythmias, myoglobinuria)
Sources:
Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed.
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
K Fraser, MB ChB FRCA , I Raju, MB BS FRCA, Anaesthesia for lower limb revascularization surgery, BJA Education, Volume 15, Issue 5, October 2015, Pages 225–230, https://doi.org/10.1093/bjaceaccp/mku042
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.