The non - selective use of profundaplasty in lower limb ischaemia BRIAN

Introduction The ability of the profunda femoris artery and its branches to maintain a viable and, in certain circumstances, normally functioning lower limb in the presence of an occluded superficial femoral artery has long been recognized. Leeds and Gilfillan (1961) and Morris et al. (1961) both described the successful treatment of groups of patients with combined aorto-iliac and femoropopliteal disease by aorta to common femoral artery bypass grafting together with an endarterectomy of the common femoral artery and profunda femoris origin where indicated. Farley, Kiser and Hitchcock (1964) described an unusual operation in which a vein graft was interposed between the termination of the main profunda femoris artery and the popliteal artery via a posterior approach, enabling an infected femoro-popliteal graft to be removed without sacrificing the limb, but operations restricted to the common femoral bifurcation were not widely accepted at that time. Waibel (1966), with a description of profunda femoris origin reconstruction using a flap from the occluded superficial femoral artery, is the first of a series of authors to describe procedures to increase profunda femoris blood flow without surgery to more proximal vessels. Interest in the profunda femoris artery increased in subsequent years, attention still mainly centring on its ability to provide adequate distal run-off for proximal bypass or endarterectomy when the superficial femoral artery was occluded, although papers by Martin, Renwick and Stephenson (1968), Youmans, Hopkins and Derrick (1969), Killen (1969) and Cohn, Trueblook and Crowley (1971) include small numbers of patients in whom surgery to the common femoral artery and profunda femoris origin, by endarterectomy or patch grafting, was the sole procedure. The use of profundaplasty as an operation in its own right has expanded rapidly in recent years and several widely differing techniques are described. Berguer, Higgins and Cotton (1975) have stressed the importance of extending any reconstructive procedure distally at least as far as the first major generation of branches of the diseased profunda femoris artery and the majority of surgeons achieve this with an autogenous vein patch of 4-5 cm with or without endarterectomy. However, Harper and Millar (1977) have reported success using a very short vein patch to the profunda femoris origin only, whilst Berguer, Cotton and Sabri (1973), emphasizing that atheroma may not be localized to the profunda origin, have described the operation of extended deep femoral angioplasty utilizing a vein patch of up to 15 cm. Amongst other techniques recorded are long semi-closed endarterectomy of the profunda femoris artery (Kiely, Lumley and Taylor, 1973) and common femoral artery to profunda femoris bypass using reversed long saphenous vein (Sproul, 1968; Berguer and Cotton, 1973). Arterial flaps (Waibel, 1966), 'Dacron' (Sproul, 1968) and autogenous vein have all been used successfully for profunda angioplasty. Authois are divided in the routine use of common femoral and profunda femoris endarterectomy together with a patch grafting technique whilst Cohn et al. (1971) report excellent results using endarterectomy alone without patch grafting. Important aspects of the radiology of the common femoral artery bifurcation were highlighted by Beales et al. (1971) who emphasized that the posterolateral inclination of the profunda femoris artery at its origin made accurate estimation of stenosis in this vessel impossible in standard A-P arteriograms. Significant profunda origin stenosis was found in 39% of patients in his study; in nearly 2/3 of these, this was only apparent on oblique or lateral radiographs. The haemodynamic theory of operations on the