1. Are We Moving Away from Surgery for the Common Femoral Lesion?
CRT 2012
David H. Deaton, MD
Chief, Vascular and Endovascular Surgery
Georgetown University Hospital
MedStar Vascular
Washington, DC

2. David H. Deaton, MD Aptus Endosystems Boston Scientific / Trivascular
U.S. Phase I Investigator
Advisory Board
Consultant
Boston Scientific / Trivascular
U.S. Phase I Investigator – Trivascular I device
Vascutek / Terumo
U.S. Phase I Investigator – Anaconda graft
Medtronic – Consultant
BioConnect – Consultant / Sci. Adv. Board
ROX Medical – Consultant / Sci. Adv. Board
Intact Vascular – Consultant / Sci. Adv. Board
GE Vascular Imaging – Consultant
David H. Deaton, MD

3. Principles of CFA reconstruction
Primary inflow to lower extremity
Preserve Profunda inflow: “Lifeline of the Leg”
Preserve percutanous access via femoral
Avoid redo procedures

4. Medicare: Trends in Physician Specialty for Endovascular
National trends in lower extremity bypass surgery, endovascular interventions, and major amputations Corrected Proof, 29 May 2009 
Philip P. Goodney, Adam W. Beck, Jan Nagle, H. Gilbert Welch, Robert W. Zwolak 
Journal of Vascular Surgery 
DOI: /j.jvs

5. Endovascular Treatment of Common Femoral Artery Disease Bonvini RF, Rastan A, Sixt S, et.al.
Retrospective analysis of 360 CFA interventions
26.9% isolated CFA interventions; others combined with inflow / outflow lesions
16.7% were CTO
POBA primary; adjunctive stenting 36.9%
> 30% stenosis still present in 7.2%
Restenosis 27.6% at one year
J Am Coll Cardiol, 2011; 58:

6. 1 and 5 Year Primary Patency 93% and 91% Secondary patency 100%
65 CFA endarterectomies
68% claud, 32% CLI
1 and 5 Year Primary Patency 93% and 91%
Secondary patency 100%
5% Major complication(hematoma, wound infection, failure to treat inflow lesion)
J Vasc Surg 2008 Oct;48(4):872-7

7. Factors To Consider in Endoluminal Reconstruction
Pros
Easy
Short, large diameter vessel
Cons
May need to stent
Jeopardize profunda
High recurrence
At joint space / easily compressed
Complicate future femoral access and surgery

8. Disaster: Loss of Common Femoral and Profunda

9. What is “Common Femoral Endarterectomy”?
Removal of all plaque en bloc from distal external iliac through orifice of profunda and SFA
Patch angioplasty (vein or prosthetic) of vertical arteriotomy
End result: Large disease free common femoral

10. Factors to Consider in Open Femoral Reconstruction
Pros
Easily accessible
Excellent acute and long term results
Allows maximum control / protection of profunda femoris
Facilitates inflow and outflow procedures
Maintains endovascular access site for coronary and other peripheral intervention
Cons
Difficult in reoperative / irradiated fiels

11. Techniques in CFA Endovascular
POBA – risk of needing stent
Directional Atherectomy
Less risk of stent
Can direct therapy at eccentric lesions
Rotational atherectomy
Stents – undesirable
Complicates access
Across joint
Jeopardizes profunda

12. Current Practice
Treat “serious” CFA disease with open endarterectomy and patch
Consider endoluminal therapy for small focal lesions complicating distal outflow endovascular interventions
Consider endoluminal in surgically inaccessible femoral anatomy

13. Thank you