PAD in Focus

Treatment of Symptomatic Common Femoral Artery Stenosis

The preferred revascularization strategy for symptomatic common femoral artery stenosis is unknown. Common femoral endarterectomy has been the preferred treatment for many years, with proponents emphasizing its feasibility, safety, durability and long-term patency. However, endarterectomy is not without risks and complications, including infection, systemic injury, bleeding and need for reoperation. The composite complication rate ranges from 10% to 15% and the 30-day mortality rate ranges from 1.5% to 3.4%.

Michael S. Lee

Endovascular treatment for common femoral artery (CFA) disease is an attractive alternative to surgical revascularization because it obviates the need for general anesthesia and its attendant risks. Furthermore, because it doesn’t require a surgical incision, the rates of periprocedural morbidity and mortality, infection, length of stay and recovery time are low. Patients are routinely discharged home on the same day of their procedure.

Figure 1. An 85-year-old man with lung cancer, severe chronic obstructive pulmonary disease and Rutherford class 3 claudication who refused endarterectomy.

All Figures provided by Michael S. Lee, MD, FACC, FSCAI; printed with permission.

The data on endovascular treatment of the CFA are limited, with most centering on percutaneous transluminal angioplasty (PTA) and stenting, often in conjunction. The available data have produced mixed results, which vary with the type of intervention utilized. Procedural success rates ranged from 90% to 95% and one study reported a composite complication rate of 6.9%. Rates of restenosis were as high as 28.7% at 1 year and 50% at 5 years, although a larger retrospective analysis reported that 83% of patients remained alive with maintained vessel patency at 1-year follow-up.

Figure 2. A 1.5-mm orbital atherectomy crown was used to modify the calcified plaque.

Controversy surrounds the implantation of stents in the CFA, as the data have provided conflicting results. The disadvantage of stent implantation of the CFA is the potential to compromise the deep femoral artery, an important collateral vessel, as well as limit the ability to perform endarterectomy in the future. Stent placement was also a predictor of reintervention and amputation. Stents also have the potential for fracture due to the repetitive stress and flexion at the hip joint. A cohort of 36 patients who underwent stenting reported that only one stent fracture was detected during a mean follow-up of 64 months, but there was an in-stent restenosis rate of 28%. Newer stents like the self-expanding interwoven nitinol stent (Supera Peripheral Stent, Abbott Vascular) may be an attractive option given that it is less susceptible to stent fracture.

Figure 3. A 6-mm x 40-mm drug-coated balloon fully expanded at 5 atm.

Given the limitations of stenting in this vascular bed, an option for calcific CFA disease is atherectomy. It has the potential advantage of debulking the calcified lesion and modifying the plaque before PTA, preferably with a drug-coated balloon. This strategy may decrease the need for stenting of the CFA by decreasing the rate of dissection while preserving the option of future endovascular or surgical revascularization. Stenting would be only performed on a bail-out basis.

In a subanalysis of the CONFIRM series, patients who underwent orbital atherectomy for CFA disease (n = 147) compared with superficial femoral artery disease (SFA; n = 1,508) had fewer angiographic complications (17% vs. 24%, P = .02), likely driven by a lower dissection rate (10% vs. 15%, P = .04). The CFA and SFA group had similar rates of flow-limiting dissection (4% vs. 2%; P = .17) and proportion of dissections requiring stenting (35% vs. 45%; P = .39). In a cohort of 25 patients who underwent directional atherectomy (Silverhawk, Medtronic), there was a procedural success rate of 96%, a complication rate of 0%, a 1-year restenosis rate of 11.8% and a 1-year target lesion revascularization rate of 4.8%.

Figure 4. Final femoral angiography demonstrates excellent angiographic results.

In conclusion, the ideal treatment of CFA disease remains controversial. The decision to treat CFA disease with endovascular intervention should be based upon clinical and anatomic features as well as patient preference. Although procedural and short-term outcomes are promising, data on long-term outcomes of endovascular treatment of CFA disease are lacking. A randomized trial comparing endarterectomy with endovascular treatment with long-term follow-up is needed to determine the gold standard for CFA disease.

Disclosure: Lee reports consulting for Cardiovascular Systems Inc.

The preferred revascularization strategy for symptomatic common femoral artery stenosis is unknown. Common femoral endarterectomy has been the preferred treatment for many years, with proponents emphasizing its feasibility, safety, durability and long-term patency. However, endarterectomy is not without risks and complications, including infection, systemic injury, bleeding and need for reoperation. The composite complication rate ranges from 10% to 15% and the 30-day mortality rate ranges from 1.5% to 3.4%.

Michael S. Lee

Endovascular treatment for common femoral artery (CFA) disease is an attractive alternative to surgical revascularization because it obviates the need for general anesthesia and its attendant risks. Furthermore, because it doesn’t require a surgical incision, the rates of periprocedural morbidity and mortality, infection, length of stay and recovery time are low. Patients are routinely discharged home on the same day of their procedure.

Figure 1. An 85-year-old man with lung cancer, severe chronic obstructive pulmonary disease and Rutherford class 3 claudication who refused endarterectomy.

All Figures provided by Michael S. Lee, MD, FACC, FSCAI; printed with permission.

The data on endovascular treatment of the CFA are limited, with most centering on percutaneous transluminal angioplasty (PTA) and stenting, often in conjunction. The available data have produced mixed results, which vary with the type of intervention utilized. Procedural success rates ranged from 90% to 95% and one study reported a composite complication rate of 6.9%. Rates of restenosis were as high as 28.7% at 1 year and 50% at 5 years, although a larger retrospective analysis reported that 83% of patients remained alive with maintained vessel patency at 1-year follow-up.

Figure 2. A 1.5-mm orbital atherectomy crown was used to modify the calcified plaque.

Controversy surrounds the implantation of stents in the CFA, as the data have provided conflicting results. The disadvantage of stent implantation of the CFA is the potential to compromise the deep femoral artery, an important collateral vessel, as well as limit the ability to perform endarterectomy in the future. Stent placement was also a predictor of reintervention and amputation. Stents also have the potential for fracture due to the repetitive stress and flexion at the hip joint. A cohort of 36 patients who underwent stenting reported that only one stent fracture was detected during a mean follow-up of 64 months, but there was an in-stent restenosis rate of 28%. Newer stents like the self-expanding interwoven nitinol stent (Supera Peripheral Stent, Abbott Vascular) may be an attractive option given that it is less susceptible to stent fracture.

Figure 3. A 6-mm x 40-mm drug-coated balloon fully expanded at 5 atm.

Given the limitations of stenting in this vascular bed, an option for calcific CFA disease is atherectomy. It has the potential advantage of debulking the calcified lesion and modifying the plaque before PTA, preferably with a drug-coated balloon. This strategy may decrease the need for stenting of the CFA by decreasing the rate of dissection while preserving the option of future endovascular or surgical revascularization. Stenting would be only performed on a bail-out basis.

In a subanalysis of the CONFIRM series, patients who underwent orbital atherectomy for CFA disease (n = 147) compared with superficial femoral artery disease (SFA; n = 1,508) had fewer angiographic complications (17% vs. 24%, P = .02), likely driven by a lower dissection rate (10% vs. 15%, P = .04). The CFA and SFA group had similar rates of flow-limiting dissection (4% vs. 2%; P = .17) and proportion of dissections requiring stenting (35% vs. 45%; P = .39). In a cohort of 25 patients who underwent directional atherectomy (Silverhawk, Medtronic), there was a procedural success rate of 96%, a complication rate of 0%, a 1-year restenosis rate of 11.8% and a 1-year target lesion revascularization rate of 4.8%.

Figure 4. Final femoral angiography demonstrates excellent angiographic results.

In conclusion, the ideal treatment of CFA disease remains controversial. The decision to treat CFA disease with endovascular intervention should be based upon clinical and anatomic features as well as patient preference. Although procedural and short-term outcomes are promising, data on long-term outcomes of endovascular treatment of CFA disease are lacking. A randomized trial comparing endarterectomy with endovascular treatment with long-term follow-up is needed to determine the gold standard for CFA disease.

Disclosure: Lee reports consulting for Cardiovascular Systems Inc.

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