Endovascular Treatment of Femoral-Popliteal Arterial Occlusive Disease

Historical Background

Dotter and Judkins first described percutaneous transluminal angioplasty (PTA) using a rigid catheter in 1964. By March 1977 approximately 1800 patients with femoral-popliteal arterial occlusions and stenoses had been treated using this technique, as reported in an international congress that included 12 European centers, to which Dotter contributed 322 cases. Grüntzig and Hopff introduced a high pressure balloon angioplasty catheter in 1974, and in 1979 Grüntzig and Kumpe reported a 2-year patency rate of 86% in 188 patients with femoral-popliteal arterial lesions that had been treated by balloon angioplasty.

The occurence of immediate recoil, dissection, and occlusion after angioplasty, as well as high rates of early recurrent stenosis, led to the development of intravascular stents. In 1987 Sigwart and colleagues described the earliest clinical experience with stenting for treatment of superficial femoral artery disease. Self-expanding stents were deployed for treatment of three patients with stenotic lesions of the superficial femoral artery and one patient after recanalization of a complete occlusion. The technique of subintimal angioplasty for recanalization of occlusions of the femoral and popliteal arteries was introduced by Bolia in 1990. This initial experience with 71 limbs was followed by a report detailing a 3-year experience in the treatment of 200 occlusions. Use of a polyester-covered stent-graft system for treatment of femoral-popliteal artery disease in 67 patients was described in 1996 by Henry. In 2000 Lammer and associates were the first to describe the use of a PTFE-covered stent-graft for treatment of superficial femoral artery disease. In 2005 the BASIL trial demonstrated that balloon-angioplasty was associated with similar amputation-free survival as surgery for patients presenting with severe limb ischemia resulting from infrainguinal arterial occlusive disease.

Indications

Endovascular treatment is the preferred approach for patients presenting with intermittent claudication or critical limb ischemia and Trans-Atlantic Inter-Society Consensus (TASC) class A and B femoral-popliteal lesions of up to 15 cm in length but not involving the popliteal artery ( Table 48-1 and Box 48-1 ). Although surgery is preferred for treatment of TASC C and D lesions, endovascular therapy may be considered for the high-risk symptomatic patient who is otherwise an unsuitable operative candidate.

Preoperative Preparation

• History, physical examination, and non invasive vascular studies. History, physical examination, and noninvasive diagnostic evaluation should be performed for all patients who present with intermittent claudication, rest pain, or gangrene of the forefoot., Acuity, clinical severity, and anatomic extent of arterial occlusive disease, as well as prior surgical or endovascular interventions, medical comorbidities, and current functional status, all influence the decision to intervene and the best method of treatment. Noninvasive vascular studies should include segmental lower extremity pressures, pulse volume recordings (PVRs), ankle-brachial index (ABI), and toe pressures. In patients with calcified, noncompressible, infrageniculate arteries, toe pressures are required for determining the severity of the underlying arterial occlusive disease.

• Duplex ultrasound. Duplex ultrasound is useful for determining the location and the severity of arterial disease. In addition, the absence of a suitable vein conduit as determined by a venous duplex study will likely influence the decision to perform a catheter-based intervention.

• CT angiography. If physical examination or other studies suggest the presence of inflow disease, computed tomography angiography can be used to assess aortoiliac disease and help plan intervention, such as the selection of an access site and potential need for femoral endarterectomy.

• Perioperative medications. All patients should be on aspirin and statin therapy before intervention, with initiation of clopidogrel when endovascular intervention is likely and the need for surgery is low.

Pitfalls and Danger Points

• Access site complications. Access site complications, including bleeding, pseudoaneurysm, or arteriovenous fistula, may be averted by using ultrasound guidance to aid in localizing and assessing the common femoral artery (CFA) with real-time visualization during access.

• Arterial dissection or rupture. The risk of arterial dissection or rupture may be minimized by avoiding excessive oversizing of angioplasty balloons. Dissections are treated with low-pressure, prolonged, repeat angioplasty or stenting, whereas rupture is treated with a stent graft.

• Distal arterial embolization. Gentle passage of wires and catheters minimizes the risk of distal arterial embolization. Embolic protection may be used for high-risk lesions.

• Acute arterial thrombosis. Ensure adequate heparinization before instrumentation of the lesion. Observation and careful control of the wire tip during delivery and retrieval of guidance and treatment catheters is essential.

Endovascular Strategy