1. 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

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

3. DISCLOSURES
DeRubertis et al. Ann Surg 2007

4. Excisional atherectomy
McKinsey et al. Ann Surg 2008

5. 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 1 year
Sarac et al. JVS 2008
Keeling et al. JVS 2007

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

7. Dr Ansel’s SFA DATA

9. Surgical Outcomes
Are they any better?
Popliteal disease
CFA

10. 4 year Lower Extremity Bypass Results
83%
72%
69%

11. 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

12. JVS 2009

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

14. SMALL INCISIONS

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

16. High Risk atherectomy/stenting? NO DATA!
GARY ANSEL

17. COMPLICATIONS

18. COMPLICATIONS

19. COMPLICATIONS

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

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

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

24. 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

25. 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

26. 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

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

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