Current state of endovascular treatment of femoro-popliteal artery disease

Abstract

Considerable advances have been made over the last decade in percutaneous technology for the treatment of atherosclerotic diseases in the femoro-popliteal arteries. While treatment strategies are well defined in the iliac segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoro-popliteal lesions continues. Whereas balloon angioplasty (PTA) is the accepted therapy for short lesions, long diffuse lesions are still recommended for surgical treatment. However, attractive new technologies ranging from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and placement of drug-eluting stents to simple angioplasty with drug-coated balloons may have the potential to replace femoro-popliteal bypass surgery as a treatment of choice for complex lesions. This article reviews the status of percutaneous endovascular techniques for the treatment of femoro-popliteal artery occlusive disease.Key words: angioplasty; percutaneous intervention; peripheral occlusive disease; popliteal artery; stent; superficial femoral artery Albert-Ludwigs-University Freiburg, Freiburg, Germany and Department of Angiology, Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany Address for correspondence: Thomas Zeller, Abteilung Angiologie, Herz-Zentrum Bad Krozingen, Südring 15, D-79189 Bad Krozingen, Germany. Tel: ϩ49 7633/4020; Fax: ϩ49 7633/402-8208; E-mail: thomas.zeller@herzzentrum.de defined as target lesion revascularization (TLR). If another lesion at the target vessel site but not the index lesion itself needs to be treated during follow-up this intervention is defined as target vessel revascularization (TVR). Superficial femoral artery and popliteal artery diseaseThe superficial femoral artery (SFA) extending to the proximal popliteal artery segment is the most commonly diseased vasculature. More than 50% of all PAD cases involve the SFA and popliteal artery. Femoro-popliteal disease is often characterized by long, diffuse lesions, long occlusions (as opposed to mild focal stenoses). The unique slow-flow and highresistance environment in the femoro-popliteal region creates a milieu that seems to increase the prevalence of de novo disease. The same issues that lead to accumulation of plaque within the femoro-popliteal region likely amplify the response to injury and may explain the high incidence of restenosis following traditional angioplasty. 9 Femoro-popliteal occlusive disease is still the Achilles heel of the vascular specialist.The durability of femoro-popliteal intervention can be predicted by the pre-procedural angiographic characteristics of the target lesion. The TASC I and the updated TASC II document 6 divided the femoropopliteal lesions into four categories (Table 1). TASC A lesions are more suitable for endovascular procedures, whereas surgery is recommended for TASC D lesions. The TASC document clearly states that it takes more evidence to make firm recommendations about the role of an...

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Cilostazol Reduces Angiographic Restenosis After Endovascular Therapy for Femoropopliteal Lesions in the Sufficient Treatment of Peripheral Intervention by Cilostazol Study

“…[1][2][3] Restenosis occurs in 40% to 60% of patients with FP disease by 12 months after percutaneous balloon angioplasty, which has been the standard and traditional endovascular revascularization procedure. [4][5][6] Recently, implantation of nitinol stents has improved the long-term outcome of endovascular therapy (EVT) for FP lesions in comparison with balloon angioplasty, 7,8 and guidelines have been revised to extend the indications of EVT because of these improvements.…”