Justification for stents in the femoral artery: a surgical point of view

Abstract

Increasingly, endovascular therapy of the superficial femoral artery (SFA) is performed using stent technology. Not only short stenoses, but also longer lesions are receiving primary endovascular treatment, although several randomized studies have shown that stenting the SFA does not improve the prognosis after PTA of lesions of this size. Rather, the stent is indicated as a secondary measure to preserve the PTA-result should complications such as a dissection occur. New technical developments such as nitinol stents, sirolimus or PTFE coated stents offer the prospect of treating more complex SFA lesions (TASC Typ C). However, randomized studies reporting long term results with such stents have yet to be published and any cost-benefit analysis of stent therapy is questionable due to lack of pertinent data. Adjunctive techniques such as laser or brachytherapy have not shown convincing improvement of endovascular SFA therapy. Compound intervention carries the risk of injury to the branching profunda or the popliteal segment, which can transform an otherwise relatively harmless SFA occlusion into a lesion which may endanger the extremity. Furthermore, increasing complexity of the SFA lesion or lesions in diabetic patients result in markedly worse results when stented, in contrast to treatment employing bypass surgery. Applying evidence based criteria to treatment recommendation shows that primary stent-PTA of the SFA is, in most cases, medically and economically unjustifiable.