Invited commentary

Abstract

The utilization of lower extremity endovascular interventions for the treatment of both claudication and critical limb ischemia has dramatically increased in the last decade. Part of this increase may be accounted for because of technological advances and part may be due to more aggressive treatment of patients considered high medical risk who would have previously been precluded from more traditional open bypass procedures. Dr Al-Nouri and colleagues have provided a detailed analysis of their institutional experience with endovascular interventions in the superficial femoral artery. Despite the small size of the study group and the cohort heterogeneity, their results have produced some important treatment options and essential patient messages that can be used by the peripheral interventionalist. First, patients with critical limb ischemia (CLI) by definition generally represent a group of persons with a heavier burden of atherosclerotic disease. As a result, these unfortunate patients also have more concomitant comorbidities than persons with claudication alone. Taking steps to reduce perioperative risk such as maximizing atherosclerotic risk factor management medically, using local or regional anesthetic modalities, employing advanced wound care techniques, or even discussing observation or primary amputation alone are all fundamental to patient care and communication. Thus, management of CLI requires a multidisciplinary team approach and detailed patient communication and understanding of the possible negative outcomes. Conversely, claudicants tend to have less diffuse peripheral vascular disease, better tibial runoff vessels, and also in many situations, better functional outcomes. Even though failed superficial femoral artery (SFA) interventions in patients with lifestyle-limiting claudication (especially TransAtlantic Inter-Society [TASC] C and D compared with A and B lesions) may not necessarily lead to amputation or bypass, the authors recommend primary bypass in those with adequate autogenous conduit. Second, both a clear assessment of the extent of lower extremity atherosclerotic disease and an extensive armamentarium of potential interventions are keys to success. In Dr Al-Nouri's series, 36% of the patients had claudication alone, whereas the other 64% had either rest pain or tissue loss. While an isolated intervention in the SFA may be adequate for improved flow in a claudicant, a person with CLI needs restoration of in-line, pulsatile flow to heal a wound or alleviate rest pain. As these patients have more diffuse disease with multiple arterial segments involved, a combination of interventions may be necessary. In cases with poor tibial runoff or a heavily diseased SFA, failure rates of isolated SFA interventions will be higher. It is not surprising that this study demonstrated that interventions performed in CLI patients with more advanced TASC C and D lesions were more likely to fail and need either bypass or amputation. With more advanced SFA disease, these patients probably had coexisting tibial disease and more heavily calcified vessels. It would be interesting to see Dr Al-Nouri's results in the treatment of multisegment disease in patients with CLI. Nonetheless, Dr Al-Nouri and colleagues had a 40% and 46% secondary patency rate for TASC C and D lesion interventions, respectively, and a 93% overall limb salvage rate. They conclude that in patients with claudication and advanced lesions, perhaps open bypass should be the treatment of choice. However, in patients with CLI, an aggressive approach to limb salvage, whether open or endovascular based upon medical risk, may be a justifiable and acceptable suggestion to primary amputation. Failed superficial femoral artery intervention for advanced infrainguinal occlusive disease has a significant negative impact on limb salvageJournal of Vascular SurgeryVol. 56Issue 1PreviewEndovascular treatment of superficial femoral artery (SFA) lesions is a well-established practice. The repercussions of failed SFA interventions are unclear. Our goal was to review the efficacy of SFA stenting and define negative effects of its failure. Full-Text PDF Open Archive