CFA, Profunda, and SFA Disease: Is There a Role for Endovascular Reconstruction When a Patient is Not a Surgical Candidate?

VASCULAR DISEASE MANAGEMENT 2018;15(11):E127-E129

Abstract

Endovascular therapy represents an additional option for treatment that is safe and efficacious in appropriately selected Rutherford class 3-6 patients with common femoral artery (CFA) occlusive disease. Atherectomy in addition to percutaneous transluminal angioplasty (PTA) has a technical success rate of 97% and has a significantly better primary patency than CFA PTA alone. Antirestenotic therapy also shows promise in treatment of these challenging patients. Furthermore, provisional stenting in the CFA may have a significant impact on improving primary patency in the long term, when alternate options fail or are not available. These data would by no means indicate a change in paradigm when managing all patients with symptomatic CFA occlusive disease; surgical common femoral endarterectomy still remains the gold standard. However, in appropriately selected patients, percutaneous CFA interventions are safe and effective.

Introduction

Common femoral artery (CFA) atherosclerosis is frequently associated with multilevel disease including the aortoiliac or femoropopliteal territories, commonly resulting in claudication and critical limb ischemia (CLI). Surgical common femoral endarterectomy (CFE) is the “gold standard” of therapy for CFA disease. The data available indicate that CFE with or without patch angioplasty has a 5-year patency rate >90%, with an incidence of postoperative complications approaching 17%.¹

Traditionally, the endovascular treatment of CFA disease has been viewed with scrutiny due to concern over potential damage to the artery from endovascular transluminal angioplasty (PTA) or atherectomy, necessitating stent placement. The CFA was long known as a “no-stent” zone because of multiple potential negative downstream effects of stenting this area, such as the possibility of inducing profound ischemia by compromising profunda collaterals, limiting future surgical options in cases of stent failure, and precluding access for endovascular procedures. Additionally, no stent technology has convincingly addressed the torsional and shear forces of this area to provide long-term patency. Due to these concerns, the endovascular treatment of CFA disease is not widely adopted; therefore, the literature evaluating patency and complications has traditionally not been robust. However, new data are being gathered comparing CFE and endovascular treatments such as the application of drug-coated balloons (DCBs) and stents. Gouëffic et al published the TECCO (Endovascular Versus Open Repair of the Common Femoral Artery) study, which evaluated the safety profile of CFA stenting when compared with surgical repair. The findings suggested that stent placement has a significantly lower morbidity and mortality at 30 days and similar clinical outcomes after 2 years when compared with surgery.² However, lack of long-term data continues to be a limiting factor that precludes stenting as a first-line therapy for CFA lesions.

Halpin et al reviewed the literature of CFE and endovascular therapies and compared findings of survival, primary patency, complications, freedom from amputation, and freedom from target-lesion revascularization (TLR).³ This meta-analysis demonstrated higher primary patency rate, but lower freedom from TLR rate, in patients who underwent CFE compared to endovascular therapy. Morbidity and mortality were higher with CFE when compared to endovascular treatment.

Nowadays, with improvements in cardiovascular comorbidity management potentially resulting in prolonged survival for vascular patients, it is not rare that endovascular options are offered for patients who are high risk for surgery and general anesthesia. In this population, percutaneous peripheral intervention (PPI) becomes a reasonable alternative. A review of the techniques that are con- sidered in such patients is presented herein.

Endovascular Techniques

When compared with CFE, the endovascular approach has lower complication rates, high technical success rates, and good short-term patency.² However, since Dotter’s seminal angioplasty, endovascular therapies have been plagued by the need for repeat interventions when com- pared with surgery. We share our experiences treating this challenging anatomical location percutaneously.

1. Percutaneous Intraluminal Angioplasy (PTA) 

Approach to CFA lesions is typically obtained by “up and over” contralateral technique or alternate strategies such as brachial, radial, and (occasionally) tibiopedal access.

PTA is the primary intervention indicated for most CFA, SFA, and profunda recanalizations, since it has the advantage of being technically less challenging and reduced hypothetical stimulus for intimal hyperplasia. The benefits of this therapy are evident when compared to stenting in this specific segment, since it preserves collateral vessels, can provide flexibility of reintervention or bypass, and is not associated with fatigue or fracturing. In addition, this therapy can be repeated. Despite these benefits and technical facility, PTA is plagued by a slightly poorer long-term patency such that often, adjunctive therapy may be beneficial. Mehta et al published CFA treatment with PTA alone demonstrating primary patency of 70% at 20-month follow-up, while Nguyen et al reported a 76.4% primary patency rate for standard endarterectomy with patch (SEP) at 18 months.^4,5

DCBs are one such adjunct (Figure 1). After appropriate vessel prep in a non-heavily calcified vessel (Fanelli calcium class 3 and 4), anti-restenotic/antihyperplastic therapy was shown to prolong patency compared with PTA.⁶ In the absence of flow-limiting dissections, this therapy is also repeatable and preserves surgical options in the future if needed. Still, the CFA is a location plagued by calcification and fibrotic plaque. In selected patients, debulking or plaque-modifying atherectomy therapy may increase drug penetration.

2. Atherectomy

This debulking technology can be applied to the CFA selectively or non-selectively (Figure 2). Atherectomy in addition to PTA has a technical success rate of 97% and has a significantly better primary patency rate than PTA of the CFA alone. In addition, decreasing calcium in this location may improve drug penetration in the vessel wall. However, the CFA is a difficult location due to the superficial femoral and profundal bifurcation. Operators must take caution to avoid embolization or occlusion of these branches. Selective atherectomy (directional and image-guided therapies, such as the Medtronic Hawk-One or Avinger Pantheris, respectively) with distal protection is one such strategy.

3. Stent Placement

Stent placement in the CFA is generally considered to be heresy in the surgical community. This is for good reason, as traditional stent technology has been limited here by fracture and thrombosis, which can in turn result in additional often worse complications. However, in selected patients, particularly critical limb ischemia (CLI) patients who are high risk for surgery, this option may in fact result in limb salvage and improved quality of life. This location is also frequently accessed for coronary and cerebrovascular angiography, so stenting in this location may decrease access options. This is further complicated by the increased frequency of coronary and cerebrovascular events^7,8 in CLI patients, so the need for access in these patients is usually not a question of “if,” but rather “when.”

Endovascular therapies should be utilized first, but consideration should be given to stenting in appropriately selected patients, given recent studies demonstrating efficacy. A purpose-driven technology (biomimetic or bioabsorbable) may confer additional benefit to the endovascular patient. Finally, techniques such as the culotte technique should be considered in carefully selected patients (Figure 3).

Conclusion

In appropriately selected Rutherford class 3-6 patients with CFA occlusive disease, endovascular therapy represents an additional option for treatment that is safe and efficacious, contrary to prior conventional teaching. Atherectomy in addition to PTA has a technical success rate of 97% and has a significantly better primary patency rate than PTA of the CFA alone. Antirestenotic therapy also shows promise for the treatment of these challenging patients. Furthermore, provisional stenting in the CFA may have a significant impact on improving primary patency in the long term, when alternate options fail or are not available. These data would by no means indicate a change in paradigm when managing all patients with symptomatic CFA occlusive disease; CFE still remains the gold standard. However, in appropriately selected patients, percutaneous CFA interventions are safe and effective. Further development of purpose-driven technology as well as multicenter randomized studies are indicated to identify appropriate selection of patients and therapy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. One or more of the authors have disclosed potential conflicts of interest regarding the content herein. The remaining authors report no related disclosures.

Manuscript submitted October 10, 2018, accepted October 25, 2018.

Address for correspondence: Robert Beasley, MD, Mount Sinai Medical Center, Director of Vascular/Interventional Radiology and Wound Care Center, 2055 NE 204th Street, Miami, FL 33179. Email: bbeaz@aol.com

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