Treatment of Femoropopliteal CTO

Abstract

The Trans-Atlantic Inter-Society Consensus (TASC) II class D femoral/popliteal lesions include chronic total occlusions (CTOs) of the superficial femoral artery (SFA) that are >20 cm in length or involve the popliteal artery. Primary stenting has proven superior to percutaneous transluminal balloon angioplasty (PTA) for FP CTOs [1]. Table 4.1 provides an overview of currently recommended treatment strategies of FP peripheral artery disease. Although surgical treatment may be preferred, current advancement of endovascular techniques and devices has made peripheral vascular intervention (PVI) often the first-line approach. Overall there are limited dedicated studies on stent versus non-stent approaches to FP CTOs. Treatment strategies for long occlusions of the SFA following successful recanalization have not been standardized, although these occlusions are frequently encountered in clinical practice. Stenting often leads to exaggerated neointimal hyperplasia leading to high in-stent restenosis rates (10–40% at 6–24 months) and stent fractures [2]. The subintimal approach can contribute to insufficient dilation and recoil after stent placement in the subintimal space, whereas the response to balloon dilation and self-expandable stenting can be more predictable and favorable with an intraluminal approach.