Loss of bifurcation patency after cross-over stenting of ostial lesions in superficial femoral artery: possible causes, prevention and reintervention

Abstract

Crossover stenting across the origin of the profunda femoral artery (PFA) and occasionally into the common femoral artery (CFA) is commonly used after suboptimal balloon angioplasty of ostial occlusive lesions of the superficial femoral artery (SFA) involving the bifurcation. Late stent occlusion at the bifurcation is not rare and results in severe lower extremity ischemia. Therefore, we tried to assess its possible causes, prevention and reintervention. Using a prospectively maintained single-center database, 12-month femoral bifurcation patency was retrospectively compared and lesion and procedural predictors of stent occlusion were determined among 63 patients (64 lesions) who between July 2011 and February 2013 underwent crossover (36 non-jailed and 15 jailed SFA, and 12 distal and 1 complete CFA) stenting of de novo ostial SFA lesions. Twelve-month overall patency rate at the femoral bifurcation was 88%, with no significant difference between jailed-ostial SFA (80%) and distal CFA (67%) stenting (P = 0.731), and significant differences between either and non-jailed ostial stenting (100%, P = 0.035 and 0.002). When PFA ostium was jailed by the stent, patients with preexisting CFA or PFA lesions had a 12-month bifurcation patency rate of 20%, significantly lower than those with simple ostial SFA lesions (83%, P = 0.015). Stent induced intimal hyperplasia caused bifurcation occlusion in 6 surgical reintervention cases. In crossover stenting of ostial lesions in SFA, bifurcation patency loss was significantly higher in distal CFA and jailed ostial SFA stenting than non-jailed ostial SFA stenting. Preexisting CFA or PFA lesion is a significant risk factor for bifurcation patency loss when PFA ostium is jailed by crossover stenting.