Debate: The Femoral Artery - Common Femoral & Popliteal Artery Stenosis: “No Stent Zones” Are Best Managed Surgically Rabih A. Chaer MD Assistant Professor.

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Presentation transcript:

Debate: The Femoral Artery - Common Femoral & Popliteal Artery Stenosis: “No Stent Zones” Are Best Managed Surgically Rabih A. Chaer MD Assistant Professor of Surgery Division of Vascular Surgery University of Pittsburgh Medical Center

My debater Disclosures need a separate talk… 4 slides and counting: stents, balloons, atherectomy devices, etc…

DISCLOSURES DeRubertis et al. Ann Surg 2007

Excisional atherectomy McKinsey et al. Ann Surg 2008

CFA. Excisional atherectomy NYP: 165 Reinterventions (nearly 30%), for recurrent symptoms, within 6 months! CCF: 1-year primary, primary assisted, secondary patency, limb salvage: 43%, 49%, 57% USF: Primary, primary assisted, and secondary patency: 61.7%, 64.1%, and 76.4% @ 1 year Sarac et al. JVS 2008 Keeling et al. JVS 2007

CFA stenting Case reports/case series Short follow up NO REAL DATA

Dr Ansel’s SFA DATA

Surgical Outcomes Are they any better? Popliteal disease CFA

4 year Lower Extremity Bypass Results 83% 72% 69%

FEMORAL-POPLITEAL BYPASS - LONG-TERM 1 0 PATENCY - FEM POP RCT % P A T E N C Y 68% 38% J Vasc Surg, 1986 MONTHS

JVS 2009

Results 105 limbs in 95 patients 10 bilateral procedures (3 simultaneous) Follow up Mean:11m Range: 1-76m Isolated CFA disease 25%

SMALL INCISIONS

Patency of the FEA site was 100% 6 y f/u after FEA with Patch 6 y after FEA without patch

High Risk atherectomy/stenting? NO DATA! GARY ANSEL

COMPLICATIONS

COMPLICATIONS

COMPLICATIONS

COMPLICATIONS MOST CRUCIAL LE VESSEL: FOR ME: PROFUNDA FOR DR ANSEL? THE LEFT MAIN

The Concept of Risk and Danger is Relative Some choose to ignore it and get away with it

But Most do not, and the risk of a Bad Outcome is quite significant.

THE FACTS COMMON FEMORAL Atherectomy/stent No data Hazardous: profunda Hi recurrence rate High need for re-intervention FEA Well established Very safe Durable Low re-intervention, in other beds LOS: Mean 2.5 days

THE FACTS POPLITEAL Atherectomy/stent Marginal outcomes Hazardous: fracture, thrombosis Hi recurrence rate High need for re-intervention Vein Bypass Well established Very safe Durable Low re-intervention, in other beds

FINAL POINTS Common femoral and retrogeniculate popliteal disease are best treated surgically INDIVIDUALIZE to good risk patients: Medically good risk Anatomically good risk: good conduit Stretch the limit in high risk patients

FUTURE Drug delivery with atherectomy Improved stent designs Bioabsorbable stents? IDEV? More flexible stents Drug eluting stents

Why stretch the limit with current outcomes and technology? CONFLICT REIMBURSEMENT SKILLS