1. Superficial Femoral Artery Disease:
Simulation Training
Curriculum

2. Superficial Femoral Arterial Disease
Prevalence
Clinical Presentation
Diagnosis
Indications
Technical Issues
Treatment Options
- PTA
- Surgical
Complications
Prognosis

3. Responsible for > 50% of PAD Cases
SFA disease:
Responsible for > 50% of PAD Cases
One of the longest vessels in the body
Torsion/compression/flexion/extension by the largest muscle group
Two flexion points
Few collateral sources
Occlusions predominate

4. Superficial Femoral Arterial Disease
Most common in men than women
Most common in older patients with concomitant coronary disease
Strong relationship between increased tortuosity and disturbed hemodynamic patterns in regions of the SFA
Predilection for the region of the adductor canal 1
1. Wood et al J Appl Physiol (6)

5. Forces Exerted in SFA Extension / Contraction 1. Torsion 2. Flexion 4.
Compression 3.

6. Superficial Femoral Arterial Disease
Isolated SFA disease predicts low amputation risk (0-1%) without surgical revascularization 1
Cumulative smoking history
Contralateral superficial femoral artery occlusion
Presence of diabetes
DISEASE PROGRESSION
Other arterial segments involved
Increasing risk of critical limb ischemia
1. Hertzer NR Circulation 1991; 83(Suppl.1):I-12 – I-19

7. Superficial Femoral Arterial Disease
Prevalence
Clinical presentation
Diagnosis
Indications
Technical Issues
Treatment Options
- PTA
- Surgical
Complications
Prognosis

8. Clinical Presentation
Claudication
Critical limb ischemia (less common)
The presence of the Profunda Femoris Artery, the main nutritive artery of the thigh, protects patients with SFA occlusion from critical limb ischemia

9. Morphological Stratification of Femoropopliteal Lesions
TASC Type A
Single stenosis less than 3 cm of the superficial femoral artery or popliteal artery
TASC Type B
Single stenosis 3 to 10 cm in length, not involving the distal popliteal artery
Heavily calcified stenoses up to 3 cm in length
Multiple lesions, each less than 3 cm (stenoses or occlusions)
Single or multiple lesions in the absence of continuous tibial runoff to improve inflow for distal surgical bypass
TASC Type C
Single stenosis or occlusion longer than 5 cm
Multiple stenoses or occlusions, each 3 to 5 cm in length, with or without heavy calcification
TASC Type D
Complete common femoral artery or superficial femoral artery occlusions or complete popliteal and proximal trifurcation occlusions
ACC/AHA Guidelines

10. Superficial Femoral Arterial Disease
Prevalence
Diagnosis
Indications
Technical Issues
Treatment Options
- PTA
- Surgical
Complications
Prognosis

11. Superficial Femoral Arterial Disease: Diagnosis
Clinical evaluation
Stevens et al JAMA 2006;295(5):584

12. Diagnostic Methods
Ankle-and Toes – Brachial Indices, segmental pressure examination
Pulse volume recording
Continuous wave doppler ultrasound
Treadmill exercise testing with and without ABI assessments and 6 minute walk test
Duplex ultrasound
Computed tomographic angiography
Magnetic resonance angiography
Contrast angiography
Hirsh et al Circulation 2006; 113(11): e
ACC/AHA Guidelines

13. Diagnostic Methods: Duplex Ultrasound
Stenosis in the superficial femoral artery visualized satisfactorily in the color mode
Ramaswami et al J Endovasc Surg. 1995; 2(1): 27-35

14. Diagnostic Methods: MRA
Lower extremity MRA showing severe stenoses in left superficial femoral artery and smaller stenoses in right superficial femoral artery.
Cochrane J Radiology Rounds MGH 2004;2(11)

15. Diagnostic Methods: CTA
The diagnostic accuracy of CT angiography has been proved superior to that of conventional arteriography in several applications
CT angiography is substantially less invasive and less expensive, and it allows three-dimensional visualization from any angle and in any direction, which cannot be achieved with projection techniques such as DSA
Coronal multi–detector row
CT angiography : Occlusion of the right superficial femoral artery (thick arrow)
Catalano et al Radiology 2004;231:

16. Diagnostic Methods: DSAB
Digital subtraction angiography (DSA) shows A the occlusion of the left common iliac artery and external iliac artery, long occlusion of both superficial femoral arteries (SFAs) with no visible stump on the left, and B restoration of both distal SFAs through collaterals (arrows)
Yılmaz et al Eur Radiol. 2002;12(4): 911-4

17. Superficial Femoral Arterial Disease
Prevalence
Diagnosis
Technical Issues
Treatment Options
- Medical
- PTA
- Surgical
Complications
Prognosis

18. Superficial Femoral Artery Technical Approach
Diagnostic Arteriogram: Showing inflow and outflow of the target lesion
Run-off angiography to visualize the lower extremity circulation
Grossmans “Catheterization” 7th Ed. pg

19. Vascular Access Antegrade common femoral artery puncture :
Most common
Contralateral retrograde access over the aortic bifurcation
Advantages:
The ability to image the common femoral and its bifurcation
The ability to treat iliac and infrainguinal disease in the same timing
Disadvantages:
Working from a distance with exchange-length wires and balloons
Retrograde popliteal artery access
Rare cases where the antegrade or contralateral approach fails to traverse an occluded segment
In the event that a subintimal channel has been created
Brachial access
Provides better radiation protection, since one is working far from the actual target site, but requires the use of lengthy wires and devices

20. Superficial Femoral Artery Anticoagulation
Aspirin (325 mg) once a day several days prior the procedure
After access has been obtained and prior to intervention: 2500 – 5000 international units of heparin

21. Superficial Femoral Arterial Disease
Prevalence
Diagnosis
Technical Issues
Treatment Options
- Medical
- PTA
- Surgical
Complications
Prognosis

22. Superficial Femoral Arterial Disease: Treatment
Patients with Claudication
Aggressive risk factor modification
Exercise program
Patients with Critical Limb Ischemia
Revascularization

23. Superficial Femoral Arterial Disease: Angioplasty
PTA is the preferred initial treatment in patients with disabling claudication 1
In patients with critical leg ischemia, PTA is better for the treatment of femoropopliteal stenosis, whereas femoropopliteal occlusion is best managed with bypass grafting 1
Percutaneous transluminal angioplasty (PTA) has been recommended only for short lesions of the superficial femoral artery 2
1. Hunink et al JAMA 1995; 274(2)
2. Dormandy JA, Rutherford B J Vasc Surgery 2000; 31:S1-S296

24. Superficial Femoral Arterial Disease: Angioplasty
Low procedural morbidity and mortality
Reduced costs
Shortened hospital stay
Preserves collaterals so that even if the angioplasty site occludes, symptoms might not return
Patients who are expected to live for less than 1–2 years and have significant comorbidity should probably, when possible, be offered angioplasty first.
If the procedure fails, the patient may not be disadvantaged in the short term and can go on to have surgery if regarded as appropriate
Adam et al Lancet 2005;366:

25. Adjunct Therapies Stents Directional atherectomy
Rotational atherectomy
Laser angioplasty
Intra-arterial radiation
Cryotherapy

26. Superficial Femoral Arterial Disease: Stenting
Is recommended only as a bailout procedure after technical failure of angioplasty
Flow limiting dissections
Residual pressure gradient >15mmHg
Remaining stenosis >30%
An elastic recoil as well as failure to maintain initial patency
Heuser R, Biamino G. Peripheral Vasc Stenting.2nd Ed

27. Superficial Femoral Arterial Disease:
Balloon Expandable Stents : Not indicated in the femoropopliteal region, with exception of short, very calcified lesions less than 2 cm in length.
The Palmaz TM stent
High radial force: valuable in highly calcified lesions
Precise placement
Disadvantage: significant stiffness
Strecker TM stents
Very flexible: Allows for a contralateral placement using crossover approach
Disadvantage: deformability by extrinsic compression, which can lead to restenosis and reocclusion in the femoropopliteal tract
Heuser R, Biamino G. Peripheral Vasc Stenting.2nd Ed

28. Superficial Femoral Arterial Disease: Stenting
Stents of choice for implantation in the SFA
Advantages over balloon expandable stents:
Higher flexibility
Recoil tendency after external deformation
The Wallstent
Difficult exact placement: shortening up to one-third
Ninitol Stents
Implantation more precise foreshortening (Max 5%)
Superior accommodation to different artery diameters

29. Duplex-guided Balloon Angioplasty and Stenting
Duplex methodology can be used to map the arterial disease process and to guide wires, sheaths, balloons, and stents for the treatment of superficial femoral
Effective in achieving excellent anatomic and hemodynamic improvement regardless of the extent of the stenotic lesion
Benefic in patients severely allergic to contrast material or those with renal insufficiency
Power Doppler image of severe (81%) superficial femoral artery stenosis. The hemodynamic significance of this lesion was confirmed by a peak systolic velocity of 388 cm/s with marked spectral broadening.
Ascher et al J Vasc Surgery 2005; 42(6):

30. Directional Atherectomy
Directional atherectomy of right superficial femoral artery. A. Angiography via antegrade punctureinto right common femoral artery demonstartes high-grade stenosis in proximal SFA, not favorable for balloon angioplasty owing to ostial location/eccentricity. B. An 8Fr directional atherectomy catheter introduced via sheat, which is then pulled back to common femoral artery. C. Angiography following DA demonstrates excellent result
Grossmans “Catheterization” 7th Ed. pg

31. Excimer laser Atherectomy
Excimer laser atherectomy of peripheral arteries has been practiced commercially in Europe since 1994 and has been shown to be a useful adjunct for the treatment of long superficial femoral artery (SFA) occlusions
Scheinert et al J Endovasc Ther. 2001;8:156–166

32. Superficial Femoral Arterial Disease:
When PTA has been attempted for more diffuse disease and long occlusions, limb salvage rates are considerably lower
Laird et al J Endovasc Ther Feb;13(1):1-11

33. A) A rather extreme case of severe ulceration with associated infection on the bottom of the foot prior to intervention. (B) At 6 months after treatment with excimer laser atherectomy , healing is nearly complete
Laird et al J Endovasc Ther Feb;13(1):1-11

34. Surgery Bypass surgery with venous grafts
Good long-term anatomical patency
Clinical durability
Bypass surgery vs. angioplasty :
Angioplasty also seems to be a much less expensive option than surgery, at least in the short term
The rates of amputation – free survival after surgery and balloon angioplasty are similar for the first two years.
Adam et al Lancet 2005;366:

35. Amputation-free survival after bypass surgery and balloon angioplasty
Adam et al Lancet 2005;366:

36. All-cause mortality after bypass surgery and balloon angioplasty
Adam et al Lancet 2005;366:

37. Poor Surgical Candidates
Severe distal tibial occlusive disease
Inadequate distal targets for revascularization,
Absent venous conduit, or
Significant medical or cardiac comorbidities rendering them at high risk for complications from surgery.
Laird et al J Endovasc Ther Feb;13(1):1-11

38. Superficial Femoral Arterial Disease
Prevalence
Diagnosis
Technical Issues
Treatment Options
- Medical
- PTA
- Surgical
Complications
Prognosis

39. Complications Acute or subacute thrombosis Restenosis Dissection
Distal embolization
Perforation
Hematoma
Stent fractures

40. Superficial Femoral Arterial Disease
Prevalence
Diagnosis
Technical Issues
Treatment Options
- Medical
- PTA
- Surgical
Complications
Prognosis

41. Unfavorable Predictors
Type of lesion (occlusion)
Long or eccentric lesions
Diffuse atherosclerosis
Limb-threatening ischemia
Poor initial post-PTA appearance
Diabetes mellitus
Congestive heart failure
Poor distal outflow

42. Favorable Predictors Higher preoperative ABI
Performance of angioplasty
Type of lesion (stenosis)

43. Percutaneous angioplasty or stenting
of the SFA
Primary Patency Rates (%)
Months
380 limbs
66% IC
The objectives of this study were to examine factors predictive of success or failure after percutaneous angioplasty (PTA) and stenting (S) of the superficial femoral artery (SFA) and to compare the results of PTA/S with a contemporary group of patients treated with femoropopliteal bypass. METHODS: A database of patients undergoing PTA and/or S of the SFA between 1986 and 2004 was maintained. Intention-to-treat analysis was performed. Patients underwent duplex scanning follow-up at 1, 3, and every 6 months after the intervention. Angiograms were reviewed in all cases to assess lesion characteristics and preprocedure and postprocedure runoff. Results were standardized to current TransAtlantic Inter-Society Consensus (TASC) and Society for Vascular Surgery (SVS) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Cox proportional hazard analyses were performed to assess factors associated with patient survival and treatment efficacy. RESULTS: Three hundred eighty total limbs underwent PTA/S in 329 patients (67% male, 33% female; average age, 65 years). Mean follow-up was 1.8 years from the date of initial intervention. Indications for intervention were claudication in 66%, rest pain in 16%, and tissue loss in 18%. Runoff at the tibial level was 2.1 +/- 0.8 patent vessels. Mean SVS ischemia grade was 3.1 (range, 1 to 5). TASC lesion grades were A (48%), B (18%), C (22%), and D (12%). Angioplasty alone was used in 63% of cases. Primary treatment failure (inability to cross lesion) was seen in 7% of patients. There was one periprocedural death. Primary patency rates were 86% at 3 months, 80% at 6 months, 75% at 12 months, 66% at 24 months, 60% at 36 months, 58% at 48 months, and 52% at 60 months. Assisted primary patency rates were slightly higher ( P = not significant). By Cox proportional hazards analysis, patency of PTA/S was associated with higher preoperative ankle/brachial index ( P = .016) and the performance of angioplasty only ( P = .011). Failed or occluded PTA/S was associated with TASC C ( P < .0001) and TASC D lesions ( P < .0001). Patient death was associated with the presence of congestive heart failure ( P = .003). Subgroup analysis revealed that primary patency rates are highly dependent on lesion type (A > B > C > D, P < .0001). PTA/S patency for TASC A and B lesions compared favorably to prosthetic and venous femoropopliteal bypass. Surgical bypass was superior to PTA/S for TASC C and D lesions. CONCLUSIONS: PTA and stenting of the SFA can be performed safely with excellent procedural success rates. Improved patency of these interventions was seen with increased ankle/brachial index and the performance of angioplasty only. Worse patency was seen with TASC C and TASC D lesions. Patency rates were strongly dependent on lesion type, and the results of angioplasty and stenting compared favorably with surgical bypass for TASC A and B lesions.
Surowiec SM. J Vasc Surg. 2005;41(2):269-78

44. 3-year Primary Patency Rates
SFA Patency Rates
Meta-analysis
3-year Primary Patency Rates
Roehring JVS 2005

45. Rates of Restenosis on Angiography
Angiplasty
Stenting
P=0.05
P=0.02
Restenosis Rate %
43%
(23 of 53)
24%
(12 of 51)
50%
(18 of 36)
25%
(17 of 68)
Schillinger et al N Eng J Med 2006;354:

46. Rates of Restenosis on Duplex Ultrasonography
Angioplasty
Stenting
P=0.36
P=0.06
P=0.01
Restenosis Rate %
23%
(12 of 53)
14%
(7 of 51)
45%
(24 of 53)
25%
(13 of 51)
63%
(33 of 52)
37%
(18 of 49)
Schillinger et al N Eng J Med 2006;354:

47. Clinical Outcomes Angioplasty Vs Ninitol Stent Group
Maximum Walking Distance (m)
Schillinger et al N Eng J Med 2006;354:

48. Comparison with Venous and Prosthetic Bypass
SFA PTA or Stenting
Comparison with Venous and Prosthetic Bypass
TASC
LESION
TASC
LESION
Surowiec SM. J Vasc Surg. 2005;41(2):269-78

49. Stent or PTA of the SFA 1986-2004:
Freedom from symptom recurrence
TASC lesion
Despite loss of patency, patients feel better. Tissue healed, better colaterals, exercise program able to be initiated etc
Surowiec SM. J Vasc Surg. 2005;41(2):269-78

50. Durability of Endovascular Intervention for Iliac and Femoropopliteal Disease
Primary Patency at 1, 3, 5, Years
TASC Working Group , J Vasc Surg 2000;31:S1-S296

51. Femoro-popliteal Bypass Graft Occlusion: Dutch BOA Study
Multicenter, randomized comparison of coumadin vs. ASA for prevention of graft occlusion
2690 patients with mean follow-up of 21 months: 51% claudicants, 48% with CLI
Conduits: 64% venous 36% prosthetic conduits
Smeets et al Eur J Vasc Endovasc Surg 2005; 30(6):604-9

52. Durability of Surgical Bypass: Multicenter Randomized VASCAN Trial
Primary patency rates (%)
328 femoropopliteal bypass operations utilizning end-to-end versus end-to-side distal anastomosis
Primary patency was 75 vs 74%, 65 vs 66% and 63 vs 55% for ETE vs ETS after
1, 2 and 3 years, respectively, (p = 0.26)
Schouten et al Eur J Vasc Endovasc Surg. 2005; 29:457-62

53. Proximal SFA occlusion

55. Excimer Laser

56. After Stenting