Polling Station

Poll 02/01/2019 – 31/01/2019

The common femoral artery (CFA) disease

Gender: Male

Age: 73 years old

Comorbidity: Arterial hypertension, hypercholesterinemia, coronary artery disease, previous CABG

Symptoms:  Claudication, Rutherford stage 3

Previous operations: None

ABI: 0.5

Question #1

Primary treatment

Which is your primary treatment for de novo common femoral artery disease?
  • Surgery

  • Endovascular treatment

The expert: Dr. Peter Schneider, MD
De novo common femoral artery disease is most often treated with femoral endarterectomy. In this case, the patient is only 73, has comorbid conditions that are under management, and is looking for a long-term solution for symptoms of claudication. In this case there are a couple of caveats to consider. 1) The patient will likely require clamp placement on the distal external iliac artery for inflow control during open surgery. If the patient is obese, this may not be a desirable maneuver and should be considered. 2) Whenever I treat a patient with open surgery that has need for clamping of the distal external iliac artery, I do it in in the endovascular suite, so that if the small chance occurs that inflow balloon control is needed, then the patient is ready for imaging. 3) Since the patient’s ABI is only 0.5, there may be other disease to treat that we do not see in this image. Certainly, the critical lesion in the proximal SFA must be treated; this can be done either open or endo.
Question #2

Morbidity and mortality

Which is the combined morbidity/mortality rate following surgical treatment of common femoral artery disease:
  • <5%

  • 5-15%

  • 16-30%

  • 31-50%

  • >50%

The expert: Dr. Peter Schneider, MD
Femoral endarterectomy has among the best long-term patency results of any procedure in vascular surgery. Reports of complications in the literature include a wide range of patients with focal disease and minimal co-morbidities and those with extensive disease and the need for concomitant procedures and multiple co-morbid conditions. It is the clinical judgement that directs the operator to an open approach in some patients and an endovascular approach in others. Two large reports in recent years have summarized risk after femoral endarterectomy. A large series from Germany demonstrated an 11.5% procedure-related complication risk at 7 years. (1) Another large study of a US database showed a 15% risk of complications within a year. (2)
Question #3

Endovascular CFA treatment

Which of the following characteristics might be an indication for endovascular CFA treatment?
  • Severe obesity

  • Chronic steroid use

  • Prior groin surgery

  • Increased comorbidity

  • None of them, endovascular treatment is not an option

The expert: Dr. Peter Schneider, MD
The most common complication after femoral endarterectomy is related to the wound. These two groups of patients are at higher risk for wound complications, especially those who have severe obesity.
Question #4

Primary endovascular CFA treatment option

Which of the following modalities would be your primary endovascular CFA treatment option:
  • Plain angioplasty

  • Drug-coated balloon angioplasty (DCB)

  • Vessel preparation and DCB angioplasty

  • Bare metal stent

  • Drug-eluting stent

  • Stent-graft

The expert: Dr. Peter Schneider, MD
My approach is consistent with number 3, vessel preparation and DCB angioplasty. I will then place a bare metal stent if the result of treatment is not hemodynamically acceptable. These are almost always heavily calcified lesions and require vessel preparation. This can be done with a modified balloon or atherectomy. DCB is best in my opinion at this stage because it does not commit the patient to a stent or other implant that may later require removal. If the result if vessel preparation and DCB angioplasty is unacceptable and scaffolding is required, I would place a bare metal stent.
Question #5

Contraindications for endovascular CFA treatment

Which of the following characteristics might be a contraindication for the endovascular CFA treatment?
  • Concomitant deep femoral artery disease

  • Concomitant SFA disease

  • Severe calcification

  • Young age

  • There is no contraindication for endovascular treatment

The expert: Dr. Peter Schneider, MD
However, most often, I use endo when a patient has a relative contraindication to endarterectomy. There are not many patients who cannot have endo for CFA disease; the choice not to do endo has more to do with having a better solution in terms of long-term results (endarterectomy) and the complexity of endo options. For example, severe calcification, a true rock, especially if associated with an occlusion, is a waste of time to treat from an endovascular standpoint.
Question #6

Rutherford 4 and CFA disease

In case of rest pain (Rutherford 4) and coexisitng CFA and SFA disease, do you think that CFA revascularization only is sufficient?
  • Yes

  • No, I would go also for SFA revascularization/bypass

The expert: Dr. Peter Schneider, MD
If the CFA disease is severe and is obstructing flow to the profunda and the profunda has good collateralization to the popliteal, CFA open repair will be a lasting solution for rest pain. If the CFA disease is not as severe or the profunda femoris is poor, then SFA revascularization is also required.
Question #7

Rutherford 5 and CFA disease

In case of minor tissue loss (Rutherford 5) and coexisitng CFA and SFA disease, do you think that CFA revascularization only is sufficient?
  • Yes

  • No, I would go also for SFA revascularization/bypass

The expert: Dr. Peter Schneider, MD
Some patients may heal on the basis of CFA treatment alone, but many will not. Because it is a tissue loss situation, aggressive revascularization is warranted. These procedures can also be staged, but the patient should be followed carefully during the interval.