Systematic review and meta-analysis of endovascular versus open repair for common femoral artery atherosclerosis treatment.

Abstract: Background encouraging recent reports on endovascular treatment of common femoral artery (CFA) atherosclerotic disease renders the question regarding the place of this technique ever-more pertinent and indeed legitimizes randomized trials. This comprehensive review focuses on early and mid-term outcomes to help assess the benefit-risk balance of endovascular versus open repair for CFA treatment. Methods Embase and Medline searches were conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement standards to identify studies from 2000 to 2018 reporting endovascular repair (ER), open surgery (OS) and those comparing both techniques for CFA atherosclerosis treatment. Outcomes measured were: 30-day mortality, morbidity and reintervention rates; mid-term patency; late reintervention and restenosis rates. Results Twenty-eight studies were eligible: 14 OS (1920 patients), 12 ER (1900 patients) and 2 comparative randomized trials (197 patients). Comparative studies meta-analysis revealed no difference in 30-day mortality and reintervention rates but improved 30-day morbidity after ER. At 1 year primary patency did not differ between ER and OS, nor did late reintervention rate. In non-comparative studies, over a mean follow-up period of 23.8 months for ER and 66 months for OS, restenosis rate was respectively 14.4% versus 4.7%. Reported stent fracture rate was 3.6%. In ER cohort, overall primary patency at 1, 2 and 3 years was 81.9%, 77.8% and 75.1% respectively. For OS cohort, overall primary patency at 1, 2 and 3 years was 93.4%, 91.4% and 90.5%. Conclusion despite expectations, current literature analysis suggests that perioperative mortality was not in favor of ER, yet perioperative morbidity advantaged ER over OS. Also, while comparable in the first year, in the long-term primary patency is much higher with OS. At present, the place of endovascular in CFA treatment still needs to be defined. Further clarification on indications and more research are required to determine both optimal endovascular technology and femoral bifurcation reconstruction with stent.