Profunda Femoris Reconstruction
PROFUNDA FEMORIS ARTERY The profunda femoris artery (PFA), or deep femoral artery, is critical to the viability of the lower extremity because it is the primary source of blood flow to the muscles of the thigh. In addition, it provides rich collateral flow to the tibial arteries in the event of significant superficial femoral or popliteal artery disease. The PFA also provides collateral flow to the pelvis in the event of common iliac or internal iliac artery occlusion. BASIC ANATOMY The common femoral artery (CFA) bifurcates into the profunda femoral artery and the superficial femoral artery (SFA) 3 to 5â•¯cm distal to the inguinal ligament. The profunda femoral artery arises from the posterolateral surface of the common femoral artery and travels in a posterior direction deep to the superficial femoral artery. The medial and lateral circumflex femoral arteries that provide collateral supply to the tibial and pelvic vessels usually arise directly from the profunda femoral artery. They do, however, originate directly from the common femoral artery 14% to 20% of the time. The PFA continues distally to give off three perforating branches to supply the muscles of the thigh before terminating in the distal thigh. The lateral circumflex femoral vein crosses anterior to the profunda femoral artery near the latter’s origin. Anatomically, the profunda femoris artery may be divided into three zones. The proximal zone (zone 1) begins at the origin of the artery and extends to the lateral circumflex femoral artery (LCFA). The middle zone (zone 2) begins at the LCFA and extends to the second perforating branch. The distal zone (zone 3) continues beyond the second perforating branch and lies deep to the adductor longus muscle. An oblique line from the anterior superior iliac crest to the medial knee corresponds to the course of the sartorius muscle and serves as a useful landmark (Figures 1 to 3). OPERATIVE ROLE The profunda femoris artery offers a variety of uses to the operating surgeon. It can provide inflow as an origin vessel, for infrainguinal procedures such as femoropopliteal bypass or femorotibial artery bypass. It can also serve as an outflow, or target vessel, for suprainguinal procedures such as aortofemoral bypass, axillofemoral bypass, femoral-femoral bypass, and iliofemoral obturator bypass. Finally, in certain situations, localized surgery on the PFA may be indicated (i.e., profundaplasty). Profunda Femoris as an Inflow Vessel Indications for use of the profunda femoris as a graft origin include inadequate available vein length, the need for concomitant extended profundaplasty, occlusion or stenosis of the superficial femoral or popliteal arteries (thereby precluding their use as an inflow vessel), and avoidance of groin scar from previous surgical reconstruction or wound infection. The profunda femoris artery tends to be spared of significant atherosclerotic occlusive disease, and when present, the disease tends to be confined to the origin or proximal portion of the PFA, especially in the patient without diabetes (Figure 4). The route for access to the PFA as an inflow source is dictated by the specific indication for operation and is tailored to the individual patient. Recognized surgical approaches include the standard anterior incision, an anterolateral and anteromedial incision, a posteromedial incision (previously called the posterior incision), and the true posterior incision. If exposure of the CFA is performed to treat occlusive disease within the CFA or proximal PFA as an addition to an infrainguinal bypass, the standard anterior approach through an extended anterior groin incision should be used. For these, the PFA is traced from its origin far enough distally to obtain suitable length for a proximal anastomosis. If the patient needs both prosthetic inflow graft revision and outflow bypass, sufficient PFA should be dissected distally to permit anastomosis of the infrainguinal vein graft to native PFA. This should be done in preference to anastomosis of the proximal vein graft to a prosthetic inflow graft. Outflow The profunda femoral artery is well suited as a critical outflow source for suprainguinal bypasses such as aortofemoral, axillofemoral, and femorofemoral bypasses. Often the profunda femoral artery outflow is crucial for maintenance of inflow graft patency. If progressive stenosis or occlusion of the superficial femoral artery occurs, the profunda femoral flow is usually adequate to support aortofemoral bypass graft outflow and maintain limb viability. Although not validated with prospective studies, intraoperative evaluation of a PFA that accepts a 4-mm probe and then allows passage of a soft catheter for 20 to 25â•¯cm implies significant runoff in the presence of SFA occlusion and proves to be adequate for patency of an aortofemoral, axillofemoral, or femorofemoral bypass (Brewster and colleagues, 1987). If the PFA does not reliably serve as the only outflow, then a synchronous distal bypass (such as PFA to popliteal artery or profunda femoral to tibial artery bypass) may be necessary. In patients with tissue loss, synchronous infrainguinal bypass with vein is preferred for in-line pulsatile flow to the foot. In some situations, a proximal groin incision is to be avoided in a femoral outflow procedure. If the groin is infected or scarred from previous operations or arteriography reveals the profunda target to be more distal, an alternative incision should be chosen. ISOLATED PROFUNDAPLASTY Although the role of isolated profundaplasty is limited it can be an effective alternative to more extensive surgery and is an important adjunct when performing concomitant infrainguinal bypass. Profundaplasty may prove useful in removal of an infected prosthetic graft from the groin, in salvage of a nonhealing above-knee or belowknee amputation, and in improvement of the clinical status of constant rest pain to intermittent claudication with limited bypass or endovascular options. It is not recommended for the treatment of tissue loss unless concomitant distal bypass is performed to provide pulsatile in-line flow to the foot. The success of an isolated profundaplasty at improvement of distal flow can be estimated with the profunda popliteal collateral index (PPCI): PPCI = AKSP − BKSP/AKSP with AKSP for above-knee segmental pressure and BKSP for belowknee segmental pressure. A PPCI of more than 0.5 indicates poor collateral development and likely failure of a stand-alone profundaplasty. A PPCI of less than 0.19 represents significant collateral development and an expected good response to isolated profundaplasty (Boran and associates, 1980). OPERATIVE APPROACHES Standard Anterior Approach The standard anterior approach is useful for access to the common femoral artery and the proximal profunda and superficial femoral arteries. It is by far the most common incision used for the aortobifemoral bypass and for infrainguinal bypasses arising from the common femoral artery. This incision is begun over the femoral pulse or, if the pulse is absent, two fingers breadth lateral to the pubic tubercle and extended distally for 5â•¯cm. The subcutaneous tissue is divided, with ligation of any visible nodal tissue or small veins and the superficial circumflex iliac vein if needed. Dissection is continued to the femoral sheath, which is then opened to gain access to the CFA and proximal profunda femoral and superficial femoral arteries. If the common femoral artery is pulseless, it often can be identified with palpation of its calcifications. Dissection should continue close to the vessel in a relatively avascular loose areolar plain. Occasionally dissection is more difficult because of the inflammatory nature of atherosclerotic disease. Vessel loops around the CFA assist with more distal dissection. Progressing distally, a visible decrease is seen in the diameter of the CFA. At this point, the PFA branches off in a posterolateral direction. Dissection continues along the lateral aspect of the CFA at the diameter change to expose the PFA. If needed, PFA dissection can be aided with either medial or lateral traction on vessel loops placed on the CFA and SFA. The PFA is a soft, thin-walled artery, and care should be taken not to avulse any of its branches. The medial and lateral circumflex femoral arteries usually arise from the PFA but as noted previously may come directly from the CFA. Their control needs to be obtained (Figure 5). Standard Anterior Approach for Extended Profundaplasty The required length of dissection of the PFA depends on extent of disease and indication for the operation. Extent of disease is judged with palpation of the artery combined with review of previously obtained imaging studies. A single view arteriogram without pullback pressures can be misleading and may underestimate significant disease layering on the posterior wall. The profunda femoris is identified at its origin as in the standard anterior approach. Further dissection distally on the PFA requires division of the lateral circumflex femoral vein where it crosses anterior to the proximal PFA. Care must be taken to remain close to the profunda femoris artery to avoid injuring femoral nerve fibers. Dissection is continued distally until past any significant disease. In the mid thigh, the adductor longus muscle must be partially divided for distal profunda exposure. The patient undergoes systemic anticoagulation with heparin. Vessels loops are pulled taunt to occlude any inflow or outflow. Profunda clamps are shaped to provide distal PFA occlusion without being cumbersome or intrusive. Because clamps do not put longitudinal tension on the vessel, the arterial back wall is not pulled close to the front wall and thus visualization of the lumen is enhanced. Arteriotomy is begun in the common femoral artery with a #11 blade and extended onto the profunda with Potts scissors until past gross disease. With significant atherosclerosis, an endarterectomy is then indicated. Proximally, in the CFA, a deep media plane is entered with an elevator, the plaque is divided, and the elevator is used to continue the endarterectomy into the PFA. Ideally, the endarterectomy is continued to the distal extent of disease where a thin, feathered endpoint is often reached. If this feathered endpoint is not seen, then the plaque is sharply divided and its endpoint tacked down with interrupted 7-0 polypropylene sutures. In the authors’ experience, tacking sutures are usually needed to prevent distal arterial flap formation and should be used liberally. Remaining medial fibers are removed with fine forceps in a radial fashion. The extended arteriotomy is closed with a vein patch. If vein is not available, a piece of occluded superficial femoral artery can be used as an autogenous patch. The needed length of this occluded artery is removed and opened longitudinally. A complete endarterectomy of the scavenged artery makes it a durable patch (Figure 6). Anteromedial and Anterolateral Approach The anteromedial and anterolateral approaches are quite similar. The anteromedial allows access to the proximal and mid zones. The anterolateral gives access to the mid and distal zones. These incisions are commonly used when groin infection or intense scarring precludes the standard anterior approach. Both incisions are parallel to the sartorius muscle and are begun along the medial or lateral border, respectively, of the sartorius muscle, dependent on the approach chosen. The sartorius is retracted medially for the lateral route and correspondingly laterally for the medial approach. Dissection is continued deep to the SFA neurovascular bundle. The PFA is found lying between the vastus medialis and adductor longus muscle. A dense connective tissue membrane, or raphe, overlying the PFA must be incised to expose the artery. If used as an inflow vessel, a pulse may be palpable through the raphe. If used for outflow, a pulse may not be palpable and continuous wave Doppler scan then aids in identifying its location (Figures 7 and 8). Posteromedial Approach The posteromedial approach has previously been referred to as the posterior approach. However, posteromedial characterization is more accurate and less confusing because there is a true posterior approach. The posteromedial approach is best used for situations in which standard groin incision is contraindicated (infection or scar), SFA occlusion is present, or an extraanatomic bypass target is required, such as in the case of an iliofemoral obturator bypass. The distal zone can be reached with this approach and allows access to the profunda femoris artery without encroachment into the subsartorial plane. With the knee flexed and the hip externally rotated, a longitudinal incision is placed on the medial thigh. The deep fascia is opened, and dissection is continued posterior to the adductor longus muscle. The profunda femoris artery is located between the deep portion of adductor longus and the adductor brevis (see Figure 7; Figure 9). Posterior Approach The true posterior approach is rarely needed, although it may be the best choice if other approaches are unsuitable because of trauma, infection, scarring, or radiation. Computed tomographic angiography may be helpful for anatomic definition in this approach. The patient is placed in the prone position. A vertical incision is placed to extend one third proximally and two thirds distally to the gluteal crease. The sciatic nerve must be identified. A plane can be developed between the biceps femoris muscle retracted medially and the vastus lateralis muscle laterally. The adductor magnus and adductor brevis are separated from the linea aspera of the femur and then retracted medially. The profunda femoris is thereby exposed. ENDOVASCULAR THERAPY Although endovascular treatment of PFA stenosis historically has been infrequently used, it is used more frequently as surgeons have become increasingly familiar with percutaneous interventional techniques. In general, PFA angioplasty is reserved for cases where severe systemic patient morbidity or intense local scarring of the groin precludes open reconstruction. Most disease in the PFA is near the artery origin and thus lends itself to endovascular treatment techniques. When the native common and external iliac and common femoral arteries are patent, a contralateral retrograde endovascular approach to the CFA is used. After heparinization, a sheath is passed over the aortic bifurcation for access to the target lesion. Angioplasty can then be performed in the standard fashion. The use of stents as a bailout procedure in the case of dissection, recoil, rupture, or significant residual stenosis remains controversial at this time. With a history of aortobifemoral bypass, passing of a sheath from the contralateral CFA across the prosthetic bifurcation seldom is feasible because of the acute angle of the prosthetic bifurcation. In the case of outflow stenosis in the PFA, a left brachial artery endovascular access is preferred. The left brachial approach allows access to either lower extremity without crossing the aortic arch and accordingly should decrease associated complications. With newer, lowprofile balloons, access through the brachial artery can be performed with a long 4F sheath (Figure 10). CONCLUSION The PFA plays an important role in maintaining viability of the lower extremity in the presence of superficial femoral or popliteal artery occlusive disease. It is a versatile vessel that serves as an outflow target for suprainguinal bypass or as an inflow source for infrainguinal bypass. Isolated profundaplasty may be useful in selected cases that do not involve tissue loss. Although controversial, the use of endovascular therapy is increasing and may become more applicable in the future as technology advances. S u g g e s t e d R e a d i n g s Bonvini RF, Rastan A, Sixt S, et al: Endovascular treatment of common femoral artery disease: medium-term outcomes of 360 consecutive procedures, J Am Coll Cardiol 58(8):792–798, 2011. Boran CH, Towne JB, Bernhard VM, et al: Profundapopliteal collateral index: a guide to successful profundaplasty, Arch Surg 115:1366–1372, 1980. Brewster DC, Meier GH, Darling RC, et al: Reoperation for aortofemoral graft limb occlusion: optimal methods and long-term results, J Vasc Surg 5:363– 374, 1987. Mills JL, Taylor SM, Fujitani RM: The role of the deep femoral artery as an inflow site for infrainguinal revascularization, J Vasc Surg 18(3):416–423, 1993. Nunez AA, Veith F J, Collier P, et al: Direct approaches to the distal portions of the deep femoral artery for limb salvage bypasses, J Vasc Surg 8:576– 581, 1988.
depicting the rich collateral network between the internal iliac artery, profunda femoris artery,and popliteal artery.
the profunda femoris artery. B, Tacking suturesplaced on distal endpoint. C, Vein patch angioplasty.
(c) arteromedial approach, (d) posteromedial approach; B, Cross sectional view of the right thigh (b)arterolateral approach, (c) arteromedial approach.