Common Femoral Artery Stenosis Research Articles

Endovascular treatment with interwoven nitinol stent for common femoral artery lesions: 2-year outcomes of a single center experience.

The study aimed was to report 2-year outcomes of endovascular treatment with interwoven nitinol (Supera™) stent for common femoral artery (CFA) lesions. We reviewed the clinical data of 20 patients who presented with CFA stenosis or occlusion and underwent balloon angioplasty followed by Supera™ stenting in CFA between February 2016 and January 2022. The outcomes were evaluated in these patients in terms of technical success, post-intervention complications, reintervention, and cumulative patency (1year, and 2years). The study included 20 patients (22 lesions) who presented with isolated CFA lesions (3), iliac lesions involving CFA (6), superficial femoral artery (SFA) lesions involving CFA (8), and extensive lesions from the iliac artery to SFA (5). There were 16 men (80%) with a mean age of 69.7years (range, 34-83). Hypertension, smoking, and diabetes were found in 15 (75%), 7 (35%), and 7 patients (35%), respectively. Clinical presentations were Rutherford stage 5 (9, 45%), Rutherford stage 4 (5, 25%), Rutherford stage 6 (4, 20%), and Rutherford stage 3 (2, 10%). Technical success was achieved in all patients (100%). The procedures for treatment were isolated CFA Supera™ stenting (1, 4.5%), CFA plus DFA Supera™ stenting (jailed SFA) (2, 9.1%), CFA plus SFA Supera™ stenting (jailed DFA) (8, 36.4%), CFA Supera™ stenting plus bare iliac stenting (Astron) (6, 27.3%), CFA plus SFA Supera™ stenting (jailed DFA) plus bare iliac stenting (Astron) (5, 22.7%), and additional DFA angioplasty (7, 31.8%). The rate of in-hospital mortality and morbidity were 0% and 10%, respectively. Distal embolization after pre-dilatation occurred in 1 patient, and cerebral infarction occurred 12h after the procedure in 1 patient. The mean follow-up time was 23months (range, 2-64). During the follow-up period, in-stent occlusion occurred in 2 patients at 9 and 46months. Re-intervention was performed in 1 patient due to recurrent symptom of claudication. The cumulative primary patency at 1year and 2years were 93.3% and 93.3%, respectively. Endovascular treatment with interwoven nitinol (Supera™) stent for CFA lesions was associated with acceptable outcomes at 2years.

Iliofemoral Artery Endofibrosis Associated with Microembolization

ObjectivesEndoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease.MethodsCase report.ResultsA 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution.ConclusionsFig 2Intraoperative appearance of iliofemoral fibrosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT) ObjectivesEndoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease. Endoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease. MethodsCase report. Case report. ResultsA 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution. A 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution. Conclusions

Common Femoral Artery Stenting: Computed Tomography Angiography Based Long-Term Patency.

Despite considerable morbid-mortality rates, common femoral endarterectomy is still considered the gold standard for atherosclerotic common femoral artery (CFA) disease. The aim of this study was to demonstrate computed tomography angiography based long-term patency after CFA stent placement and to analyze associated risk factors for restenosis. A retrospective and observational study was carried out in consecutive patients treated with endovascular stent placement in CFA lesions. A clinical follow-up and imaging study was performed using MD-CTA to assess different degrees of in stent restenosis (ISR) and primary, assisted, and secondary patency rates. In a 5-year period, 35 extremities were treated in 33 patients with self-expandable nitinol stents. The technical success was 100% without complications related to the procedure. The mean follow-up (FU) was 32.2 months, and 8 limbs were lost. The degree of CFA stenosis was reduced from 79.69 ± 26.47% to 11.23 ± 24.53%. ISR < 20%, 20-70%, and ≥ 70% was evident in 15 (55.6%), 9 (33.3%), and 3 (11.1%) limbs, respectively. Estimated primary, assisted, and secondary patency was 79.5, 96.3, and 96.3%, respectively, after 24 months and 79.5, 96.3, and 96.3%, respectively after 60 months, with a freedom of clinical driven target lesion revascularisation rate of 87.8%. Endovascular treatment with self-expandable nitinol stents in CFA lesions had a high technical success rate and was related to few complications. A mild form of intimal hyperplasia was observed in a considerable number of cases. However, long-term patency was high; therefore, CFA stent placement might be a suitable therapeutic alternative in selected patients.

Efficacy of Multichannel Balloon Angioplasty in Calcified Common Femoral Artery Lesions

This report describes 7 cases in which multichannel balloon angioplasty was performed for severely calcified common femoral artery stenosis. After the successful passage of a guidewire through the stenosis, another guidewire with a tip load of 12g or 14 g was passed through a different channel inside the calcified plaques, followed by balloon angioplasty via each route. After the procedure, ankle brachial index improved from 0.49 ± 0.23 to 0.89 ± 0.05 on an average, and 6 of the 7 patients had patent arteries at a median follow-up period of 13 months. Multichannel balloon angioplasty offers the promise of being an effective endovascular intervention to expand calcified lesions.

Outcomes of routine use of percutaneous access with large-bore introducer sheaths (>21F outer diameter) during endovascular aneurysm repair

ObjectiveThe objective of this study was to evaluate the performance of percutaneous femoral access with large-bore sheaths (>21F outer diameter) mainly employed for thoracic and thoracoabdominal aortic endovascular treatment and to stratify the outcomes on the basis of the introducer size. MethodsBetween December 2015 and December 2018, all consecutive patients who received endovascular repair through a percutaneous approach with a suture-mediated vascular closure device (VCD) and the preclose technique were included in a retrospective single-center study called Totally Percutaneous Approach to Endovascular Treatment of Aortic Aneurysms (PEVAR-PRO). The morphologic characteristics of the access vessels and patients' demographics were recorded, and 30-day closure success was defined as the primary end point. Analysis of the closure success comparing large-bore sheaths vs small-bore sheaths (≤21F outer diameter) was performed after 1:1 propensity score matching of preoperative confounding variables. ResultsThe closure success rate of the entire study cohort was 94% (622 femoral accesses in 360 patients; median age, 74 years; 84% male). Univariate analysis identified eight different factors associated with failure, but only two remained significant on multivariate analysis: diabetes (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .011) and common femoral artery stenosis >50% (OR, 4.5; 95% CI, 1.3-13.7; P = .019). After propensity score matching (1:1, 172 femoral accesses per group), closure success rate was not significantly different between large-bore and small-bore sheaths (90.7% vs 93.0%; P = .43). Multivariate analysis of the large-sheath group identified two factors associated with failure: small (<9 mm) femoral arteries (OR, 6.9; 95% CI, 1.5-31.6; P = .13) and access vessel calcifications involving more than one-third of the circumference (OR, 7.9; 95% CI, 2.1-29.4; P = .002). Neither previous femoral cutdown (44 accesses [23%]) nor percutaneous closure with VCDs (38 accesses [20%]) affected the closure success rate in the large-sheath group. Closure failure did not significantly increase the need for postoperative blood transfusions or hospital length of stay. ConclusionsOff-label use of VCDs and the preclose technique for percutaneous approach with large-bore sheaths needed for complex aortic endovascular procedures is safe and feasible. Closure success rate is not significantly different from that obtained with on-label application of VCDs with smaller sheaths.

Directional Atherectomy of the Common Femoral Artery. Learning Curve and One Year Follow up

Introduction: The use of Directional Atherectomy (DA) with or without anti-restenotic therapy (ART) may be considered for the management of common femoral artery (CFA) occlusive disease because of its minimally invasive nature with early mobilisation, reduced incision complications and infection rates [1-5]. However, it has recognised complications, which may be related to the learning curve. We present our initial experience using DA and suggest changes that may, based on our practice, improve outcomes. Methods: A consecutive series of patients who underwent CFA DA +/- ART for chronic limb ischemia with > 70 % CFA stenosis in two tertiary hospitals between June 2017 and December 2018 are described here. All of them had Ultrasound (USS) and /or Computerised Tomography Angiogram (CTA) before the procedure. Data were collected prospectively and retrospectively evaluated. The primary endpoints were technical success (< 50% residual stenosis in the CFA measured by USS after the procedure), primary patency of the CFA measured by USS at 1, 3, 6 and 12 months and also morbidity and mortality. Secondary endpoints were change in Rutherford-Becker class, target lesion revascularisation rate and length of stay post-procedure. Patients were selected for DA by the treating surgeon based on IFU and significant comorbidities. CFA DA was performed in isolation or in conjunction with other endovascular treatment of the iliac/ipsilateral femoral or tibial vessels Results: Between July 2017 and December 2018, 25 patients underwent CFA DA. Two had an occluded CFA and 23 had >70% CFA stenosis as determined by USS [6, 7] and CTA preop. There were no deaths within 30 days. Procedure-related complications included 2 cases of CFA pseudoaneurysm (one of them repaired by open surgery) (Figure 1 and Figure 2) and 1 CFA perforation (repaired with covered stent). No distal embolisation or limb loss occurred. The mean length of stay was: 1.96 days. The primary and secondary patency at 3 and 6 months was 100%. At 12 months it was 96%. Conclusion: Early results suggest that CFA DA ± ART is safe & effective and may be advantageous over open endarterectomy in some patients. However preoperative imaging or intravascular USS (IVUS) may be required to ensure that the device passes are in areas of highest plaque burden to avoid early complications and localised dilatation over time.Figure 2A: Pre DA. B: Post CFA DA + EIA Viabahn. C: Duplex USS 6 month later. D: 6 months later.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: Nothing to disclose

Percutaneous Access with Larger Introducers Sheaths (&gt;21f) During Endovascular Repair of Thoracic and Thoraco-Abdominal Pathology: A Propensity Matched Analysis

Introduction: To evaluate the feasibility and safety of an off-label percutaneous approach during the endovascular treatment of thoracic and thoracoabdominal pathology with large sheaths (>21F), even in the presence of predictors of technical failure. Methods: From December 2015 to December 2018, all patients receiving a percutaneous approach for endovascular treatment of aortic pathology (EVAR: 389 cases - 60.9%; TEVAR: 163 cases - 25.5 %, FEVAR= 87 cases - 13.6%) were enrolled in an ambispective study called PEVAR-PRO (clinicaltrials.gov: NCT03484013). The entire retrospective arm of the study was analyzed to identify the predictors of technical failure at univariate analysis. The identified predictors were used to create a 1:2 propensity matched cohort to compare the technical success rate of cases receiving a large sheath (LS) to small sheath (SS) percutaneous closure. All the enrolled PEVAR-PRO patients received two suture-mediated vascular closure devices, employing the “pre-close technique” with ProGlide (Abbott Vascular, Santa Clara, Calif) and the 30-day technical success was defined as a successful hemostasis without evidence of bleeding, pseudoaneurysm formation, arterial occlusion or dissection requiring secondary intervention. Results: The univariate analysis of the 639 femoral arteries in 363 patients (Male 84%, median age: 72 years IQR: 68-78) enrolled in the study observed that the failure predictors were: Diabetes (RR: 3.4, p< .001), SVS score >12 (RR: 2.3; p=.017), common femoral artery stenosis ≥5 0% (RR: 6.0, p< .001), femoral calcifications involving more than 33% of the vessel circumference (RR: 2.6, p=.002) and femoral anterior calcifications (RR: 2.3, p=.031). At univariate analysis a borderline lower technical success (90.8% vs 95.0%, p=.057) was observed comparing LS group (191 cases) to SS group (448 cases). After 1: 2 propensity score matching we obtained a SS group (n=346 patients: male 85%, median age: 75 years IQR: 70-79) and LS group (n=173 male: 80%, median age: 71 years IQR: 65-77) with no significative differences regarding other preoperative risk factors. The technical success rate did not differ between the two groups (LS group 90.8% vs SS Group 94.2%, RR: 1.6, IC95%: 0.85-3.01, p=.143). Interestingly, in LS group a technical failure for bleeding (6 cases - 38%) or vessel occlusion (11 cases - 62%) did not show an increased need for postoperative blood transfusions (11.4% vs 7.8%). Moreover, a previous open (42 cases - 24.3%) femoral or percutaneous (35 cases - 20.2%) access did not affect the technical success rate (open: 90.5% vs 90.8% and percutaneous: 88.6% vs 91.3%). Conclusion: An off-label percutaneous approach with pre-close technique to thoracic and thoraco-abdominal aortic pathology employing large sheath (> 21F) is feasible and safe even in presence of redo accesses. Technical success rate is not different when compared to an in-label use of the closure devices even after propensity matching toward failure predictors. Prospective controlled studies are needed to include large sheath access into the instructions for use of the device. Disclosure: Nothing to disclose

Femoral Bifurcation Morphological Analysis: Optimal Diameter of the Common Femoral Artery Stent

Introduction: Common femoral artery (CFA) stenting appears as a promising treatment for de novo CFA stenosis. Nevertheless, stenting of CFA bifurcation lesions is complex because of harmonious asymmetric geometry between the CFA and deep or superficial femoral artery. In order to ensure an optimal flow and to reduce the risk of restenosis, the stents must be implanted according to the diameter of the CFA and the diameter of the daughter vessels. In daily practice, to optimize the implantation of stents in this bifurcation, a fast and efficient method is needed to guide the physician during the procedure. The aim of our study was to validate a mathematical formula for the CFA bifurcation and to compare it to 4 existing models. Methods: We retrospectively included all patients who underwent transcatheter aortic valve implantation and who had a healthy CFA bifurcation on the CT-scan. Diameters of the mother vessel (Dm) and of each daughter vessel (Dl: larger daughter vessel; Ds: smaller daughter vessel) were measured. The ratio between the CFA and the two daughter vessels [Dm / (Dl + Ds)] was calculated, which made it possible to propose our mathematical model [Dm= (Dm / Dl + Ds) x (Dl+Ds)]. The diameter of the mother vessel was calculated according to the four existing validated physical models (Murray, HK, Flow, Finet). Finally, we calculated the relative error between the prediction of the four models and the measurements. Results: 110 CFA bifurcations from 60 patients were included. Mean mother-vessel (CFA) diameter was 7.75 ± 1.67 mm. Mean larger daughter-vessel diameter was 5.79 ± 1.21 mm and mean smaller daughter-vessel diameter was 5.23 ± 1.09 mm. A reduction of 25 % was seen between the mother-vessel and the larger daughter-vessel. The mean ratio between the CFA and the daughter vessels was 0.71. Mean angle between the superficial femoral artery (SFA) and the deep femoral artery (DFA) was 28.47° ± 5.51°. Murray's law was the only law to have a statistically significant deviation from the reel mother-vessel diameter (p< 0.001). Our model and the flow law were the most accurate with a relative difference of 1.59 ± 11.97% and 1.01 ± 11.94%, respectively. The HK and the Finet law are acute when the daughter diameters ratio are greater than 0.8. Conclusion: We developed a simple fractal ratio between the CFA and the daughter vessels [Dm=0.71 x (Dl+Ds)]. This ratio could be easily used in daily practice during CFA percutaneous reconstruction to identify the optimal diameters of the diseased vessels. Disclosure: Nothing to disclose

The Common Femoral Artery Bifurcation Lesions: Clinical Outcome of Simple Versus Complex Stenting Techniques – An Analysis Based on the TECCO Trial

Common femoral artery (CFA) stenting appears as a promising alternative treatment to the open surgery for de novo CFA stenosis. The stenting of lesions just located at the CFA is simple, whereas stenting of CFA bifurcation lesions is more complex, and outcomes are still matter of debate. The aim of this study was to describe and to compare clinical outcomes of techniques used to treat simple over complex lesions for the stenting of CFA lesions. From the French randomized controlled trial, TECCO, a total of 54 patients underwent stenting intervention and were enrolled in this study. Patients were excluded if they had CFA thrombosis, restenosis, and nonatheromatous lesions. Patients were classified by simple and complex lesions based on the type of lesion. The primary end point was the primary sustained clinical improvement. Eighteen patients were included in the simple lesion group, and 36 patients, in the complex lesion group. Baseline characteristics of patients were comparable between the 2 groups. The technical success was 100% in the simple lesion group and 91.7% in the complex lesion group. There was no significant difference between the 2 groups, regarding the primary sustained clinical improvement. The primary patency rates at 24months for simple and complex lesion groups were 86.3% and 79%, respectively (P=0.66). Freedom from target lesion revascularization was of 93.3% and 82% in the simple and complex lesion group, respectively (P=0.34). The stenting technique for CFA bifurcation lesions is a safe and effective technique. More trials with a large number of patients are needed to define the optimal stenting technique.

Confirmation of no Common Femoral Artery Stenosis Following Percutaneous EVAR

Confirmation of no Common Femoral Artery Stenosis Following Percutaneous EVAR

Intravascular Images of Common Femoral Artery Stenosis as a Complication of the Repeated Use of a Suture-mediated Closure Device

Intravascular Images of Common Femoral Artery Stenosis as a Complication of the Repeated Use of a Suture-mediated Closure Device

An Anatomical and Morphological Assessment of Common Femoral Disease and Potential Suitability for Endovascular Intervention

Open surgery for common femoral artery stenosis is safe and effective in the long-term. Endovascular interventions of the common femoral artery (CFA) is becoming more common. This study determines the anatomy and lesion morphology relevant for endovascular management of CFA atherosclerosis. We assessed a consecutive series of patients who underwent a common femoral endarterectomy over a one-year period. Where possible, CT imaging was assessed for the following relevant finding (a) contralateral iliac TASC scoring (b) angulation of the aortic bifurcation (c) CFA length and PFA (to the first bifurcation) length (d) presence of significant plaque within the ipsilateral proximal SFA (e) calcium burden within the CFA. A total of 56 patients underwent CFA endarterectomy of which 36 patients (32 men; median age 73 [68–76] years) had suitable CT imaging for analysis. Seven patients had contralateral iliac TASC C lesions, 10 TASC B and 19 TASC A. Eight patients underwent concomitant ipsilateral iliac angioplasty. The mean angle of the aortic bifurcation was 53.7°. 42% of patients had a CFA stenosis >75%. Median CFA length was 39 mm, PFA length 57 mm and 19% of patients had significant SFA disease (TASC C/D). Overall median CFA calcium score was 1543 (747 – 2047). While the endovascular enthusiasts suggest angioplasty / stent of the CFA has low peri-procedural morbidity, & study suggests that there are a number of anatomical challenges that may provide challenges for its widespread use.

Peripheral Artery Diseases

Peripheral arterial diseases (PADs) compromise blood flow to the limbs. Common causes of arterial obstruction include atherosclerosis, thrombus, embolism, vasculitis, arterial entrapment, adventitial cysts, fibromuscular dysplasia, arterial dissection, trauma, and vasospasm. The most frequently encountered cause of PAD is peripheral atherosclerosis. This chapter considers its epidemiology and risk factors, as well as its diagnosis, including clinical presentation and noninvasive diagnostic tests. This chapter also discusses acute arterial occlusion, atheroembolism, popliteal artery entrapment, thromboangiitis obliterans, and acrocyanosis, as well as the etiology, diagnosis, and treatment of Raynaud phenomenon. The chapter contains 4 tables and 7 figures. Tables describe the Fontaine classification and clinical categories of chronic limb ischemia, provide examples of leg segmental pressure measurements in a patient with calf claudication and foot pain, and summarize secondary causes of Raynaud phenomenon. Figures include a photograph of an ischemic foot demonstrating dependent rubor, measurement of the ankle:brachial index, ultrasonography of a stenosis of the right common femoral artery, magnetic resonance angiograms of patients with calf claudication, arteriograms of critical ischemia of the foot and of disabling claudication of the leg, and ischemia of the toes caused by atheroemboli. This chapter contains 80 references.

Peripheral Artery Diseases

Peripheral arterial diseases (PADs) compromise blood flow to the limbs. Common causes of arterial obstruction include atherosclerosis, thrombus, embolism, vasculitis, arterial entrapment, adventitial cysts, fibromuscular dysplasia, arterial dissection, trauma, and vasospasm. The most frequently encountered cause of PAD is peripheral atherosclerosis. This chapter considers its epidemiology and risk factors, as well as its diagnosis, including clinical presentation and noninvasive diagnostic tests. This chapter also discusses acute arterial occlusion, atheroembolism, popliteal artery entrapment, thromboangiitis obliterans, and acrocyanosis, as well as the etiology, diagnosis, and treatment of Raynaud phenomenon. The chapter contains 4 tables and 7 figures. Tables describe the Fontaine classification and clinical categories of chronic limb ischemia, provide examples of leg segmental pressure measurements in a patient with calf claudication and foot pain, and summarize secondary causes of Raynaud phenomenon. Figures include a photograph of an ischemic foot demonstrating dependent rubor, measurement of the ankle:brachial index, ultrasonography of a stenosis of the right common femoral artery, magnetic resonance angiograms of patients with calf claudication, arteriograms of critical ischemia of the foot and of disabling claudication of the leg, and ischemia of the toes caused by atheroemboli. This chapter contains 80 references.

Stenting or Surgery for De Novo Common Femoral Artery Stenosis

ObjectivesThe TECCO (Traitement des Lésions Athéromateuses de l’Artère Fémorale Commune par Technique Endovasculaire Versus Chirurgie Ouverte [Endovascular Versus Open Repair of the Common Femoral Artery]) trial is a randomized comparison of safety and efficacy of stenting versus open surgery for de novo common femoral artery (CFA) stenosis. BackgroundSurgery for CFA lesions is considered effective and durable. Despite the widespread use of endovascular repair for infrainguinal disease, the value of this procedure for such lesions is uncertain. MethodsFrom February 23, 2011, to September 5, 2013, a total of 117 patients with de novo atherosclerotic lesions of the CFA were randomly assigned to undergo surgery (n = 61) or stenting (n = 56). The main exclusion criteria were asymptomatic disease, restenosis, and thrombosis of the CFA. The primary outcome was the morbidity and mortality rate within 30 days. This includes any general complications or local complications that caused or prolonged hospitalization and/or re-intervention, lymphorrhea of more than 3 days, and post-operative paresthesia that required drugs. The median duration of follow-up was 2 years (interquartile range [IQR]: 19.8 to 24.9 years). ResultsPrimary outcome events occurred in 16 of 61 patients (26%) in the surgery group and 7 of 56 patients (12.5%) in the stenting group (odds ratio: 2.5; 95% confidence interval: 0.9 to 6.6; p = 0.05). The mean duration of hospitalization was significantly lower in the stenting group (3.2 ± 2.9 days vs. 6.3 ± 3 days; p < 0.0001). At 24 months, the sustained clinical improvement, the primary patency rate, and the target lesion and extremity revascularization rates were not different in the 2 groups. ConclusionsIn patients with de novo atherosclerotic lesions of the CFA, the perioperative morbidity and mortality rate was significantly lower among patients who underwent endovascular therapy by stenting compared with surgery, whereas clinical, morphological, and hemodynamic outcomes were comparable at mid-term. (Traitement des Lésions Athéromateuses de l’Artère Fémorale Commune par Technique Endovasculaire Versus Chirurgie Ouverte [Endovascular Versus Open Repair of the Common Femoral Artery] [TECCO]; NCT01353651)

The Role of the Profundoplasty in the Modern Management of Patient with Peripheral Vascular Disease

The occlusion of superficial femoris artery (SFA) is a common feature in peripheral vascular disease, so the profunda femoris artery (PFA) is a crucial collateral pathway for the perfusion of the lower limb. The purpose of this study is to discuss the safety, clinical, and hemodynamic efficacy of profundoplasty on the basis of limb salvage, patency, and freedom from reintervention rates. Furthermore, this study aims to identify the risk factors linked to the failure of the procedure. The study is based on a retrospective analysis of prospectively collected data of identified patients who underwent profundoplasty from March 2005 to October 2015. All patients showed a hemodynamic stenosis, extended from the posterior wall of the common femoral artery (CFA) into the origin of the PFA and concomitant occlusion of SFA. Endarterectomy with patch angioplasty was performed in all cases. In patients with concomitant iliac occlusive disease, a hybrid treatment was carried out to restore an adequate inflow through an endovascular approach. Seventy-four profundoplasty were performed during the study period. Isolate profundoplasty was performed in 56 cases (75.7%), while in the remaining 18 cases (24.3%), concomitant endovascular treatment of iliac lesions was performed. Hemodynamic success was achieved in 90.5% of the cases. The mean ankle-brachial index significantly improved, rising from 0.36±0.17 preoperatively to 0.57±0.20 postoperatively (P<0.001). The median follow-up period was 33months. Primary patency rate was 98.5% at 12, 36, and 60months. Freedom from reintervention rate was 97% at 1year and 95.3% at 3 and 5years. Limb salvage rate was 96.9% at 1year and 92.7% at 3 and 5years. Survival rates were 86%, 60%, and 47.4% at 1, 3, and 5years, respectively. Multivariate analysis identified Rutherford class 5 or 6 lesions as the strongest predictors of major amputation or reintervention (odds ratio, 9.37; confidence interval: 0.98-89.27; P=0.05). Profundoplasty is a durable, safe, and effective procedure in terms of clinical and hemodynamic results for patients characterized by occlusion of SFA and stenosis of CFA extended to profunda ostium. For patients with Rutherford category 5 and 6 ischemia, the only profundoplasty does not seem to be adequate, and concomitant distal bypass should be necessary to improve limb salvage and decrease reintervention rate.

Management of Isolated Atherosclerotic Stenosis of the Common Femoral Artery: A Review of the Literature.

Common femoral endarterectomy (CFE) remains the standard of care for treatment of atherosclerotic stenosis of the common femoral artery (CFA). Endovascular interventions have become the first-line therapy for atherosclerotic disease of the aortoiliac and femoropopliteal systems. Recent reports have documented high rates of technical success and low rates of complications with endovascular management of CFA stenosis. This study is a contemporary review of the surgical and endovascular literature on the management CFA stenosis and compares the results of these methods. A search of OVID Medline identified all published reports of revascularization of isolated atherosclerotic CFA stenosis. For each study selected for review, the number of patients, number of limbs treated, percentage of patients with critical limb ischemia, and mean length of follow-up was recorded. Study end points included survival, primary patency, freedom from target lesion revascularization (TLR), freedom from amputation, and complications. The review included 7 CFE studies and 4 endovascular studies. Survival was similar between the groups. Primary patency was consistently higher with CFE compared to endovascular therapy. Freedom from TLR was lower with CFE compared to endovascular therapy. Morbidity and mortality was also higher with CFE compared to endovascular therapy. Freedom from amputation was not consistently reported in the endovascular studies. There is limited data to support endovascular treatment of isolated CFA atherosclerosis. CFE has durable results, but there is significant morbidity and mortality resulting from this procedure. Endovascular interventions have low rates of complications, high rates of technical success, good short-term patency but increased need for repeat interventions when compared to surgery. Further trial data comparing CFE with endovascular therapy is needed to guide the management of CFA stenosis.

Results of common femoral artery thromboendarterectomy evaluation of a traditional surgical management in the endovascular era

The aim of this study was to investigate the long-term outcome of common femoral artery thromboendarterectomy in patients with peripheral arterial occlusive disease. The study retrospectively evaluated 713 vessels in 655 patients (75% male; mean age, 69.4± 9.5years) who underwent common femoral thromboendarterectomy from January 2006 until May 2012 in two high-volume vascular centers. Critical limb ischemia was present in 221 patients, and intermittent claudication was present in 434. Three patent tibial arteries, described as runoff vessels, were available in 33% of the cohort, two were present in 28.3%, one runoff vessel was present in 23.4%, and 15.2% (n= 102) showed no runoff option. Hybrid procedures were used to treat 255 limbs (35.8%). The primary end point was primary patency (PP). Secondary patency (SP), limb salvage, and survival were the secondary end points. Survival rates were 93.9%, 83.0%, 74.1%, and 60.1% at 1, 3, 5, and 7years, respectively. PP was 78.5% and SP was 89.1% at 7years. Patency rates were 97.3% (PP) and 97.8% (SP) at 6months and 90.2% (PP) and 98.3% (SP) at 3years, respectively, with 76 target lesion revascularizations. No significant difference was demonstrated for PP rates stratified for nonhybrid procedures and hybrid procedures (78.1% vs 78.6%; P= .22) and for critical limb ischemia vs intermittent claudication (76.3% vs 79.4%; P= .20) at 7years. The mean± standard deviation ankle-brachial index increased from 0.46± 0.3 preoperatively to 0.81± 0.2 postoperatively and to 0.77± 0.3 at 7years (P< .001). A total of 20 major amputations were performed, achieving a limb salvage rate of 92.6%. Procedure-related complications occurred in 11.5% during 7years of follow-up. Open surgery for common femoral artery stenosis is safe and effective in the long-term. Endovascular therapy will need to compete with these excellent results.

Commentary on ‘Predictors of Failure of Closure in Percutaneous EVAR Using the Prostar XL Percutaneous Vascular Surgery Device’

Actual outer diameter corresponding to the size given by the manufacturer in mm Size in Fr given by manufacturer 12F 14F 16F 18F 20F 22F In their paper, Rijkee et al. evaluated predictors of failure of closure in percutaneous endovascular aneurysm repair (P-EVAR) using the Prostar XL Percutaneous Vascular Surgery Device (Abbot Vascular, Santa Clara, CA, USA) in a consecutive series of 154 percutaneous accesses performed in 84 patients over a 40 month period. The team was experienced: P-EVAR was performed in 69% of the population treated. The pre-operative status of the common femoral artery (CFA) was properly evaluated on computed tomography (CT) scan, and puncture was systematically performed under per-operative ultrasound guidance to control the site of puncture and to avoid severe calcifications and atheromatous plaques. The authors demonstrated that the use of the Prostar XL device in P-EVAR was safe and feasible, with a success rate of 93.5% in a selected population excluding patients with circumferentially calcified femoral access sites or CFA stenosis. Failure to close access sites was defined as the need for conversion to conventional femoral cutdown to stop bleeding or correct vessel obstruction. In an attempt to predict failures, two potential new factors: (i) a specific calcification and location score system, and (ii) the SA-ratio (the ratio between sheath and CFA diameters) were proposed. This newly introduced calcification quantity and location score system evaluated the degree of arterial wall calcification on CT angiography, which was defined in a percentage of total wall circumference: grade I ( 50%, except circumferentially calcifications). Calcification location was classified as none or posterior, scattered anterior, and fully anterior, but this classification failed to predict failure. This result is probably related to the fact that the authors did the right thing by excluding patients with circumferentially calcified and stenotic CFAs, and puncturing under ultrasound guidance avoiding calcifications and then favoring femoral cut down in non-favorable CFAs. The other indicator was the SA ratio. The SA ratio was demonstrated to be a significant predictor of failure with a

Intraluminal Snared-Atheroma Causing Common Femoral Artery Stenosis after Using Perclose Suture-Mediated Closure System

Intraluminal Snared-Atheroma Causing Common Femoral Artery Stenosis after Using Perclose Suture-Mediated Closure System