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Endovascular Therapy for Common Femoral Artery: Is the Tide Turning?

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Presentation on theme: "Endovascular Therapy for Common Femoral Artery: Is the Tide Turning?"— Presentation transcript:

1 Endovascular Therapy for Common Femoral Artery: Is the Tide Turning?
Katrine Zhiroff, MD, FACC, FSCAI USC Keck School of Medicine Los Angeles, CA

2 Disclosures Terumo (Consultant) Biotronic (Consultant)
Abiomed (Consultant) Novartis (Speakers’ bureau)

3 Objectives Review surgical data for CFA revascularization
Anatomical considerations for endovascular approach to CFA therapies Review of available data on CFA endovascular treatment Clinical appropriateness of CFA intervention

4 Common Femoral Artery Revascularization
“Gold Standard” = Surgical revascularization Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) No specific guidelines on isolated CFA disease TASC C/D for chronic total occlusion of CFA Nogren et al. JVS (1): Supplement S Vartanian et al. Circ Res. 2015;116:

5 Historical Surgical Data (Cardon 2001)
110 endarterectomies, 101 patients 48% IC and 52% CLI 84.5% procedural success Perioperative mortality rate was 1% Local morbidity rate was 21.6% 18% of minor complications Mean follow-up was 43 months in 90 patients Primary patency 94.9% at 3 yrs and 88.8% at 5 yrs 52% were limb salvage = CLI only CFA in 20% of cases (patch angioplasty in 55% of cases) common and deep femoral arteries in 50.5% of cases (82% of patch) CFA, DFA and SFA at its origin in 29.1% of cases (93% of patch) Cardon et al Ann Chir.  2001 Oct;126(8)

6 The primary end point was primary patency
713 vessels with CFE 67% IC and 33 % CLI The primary end point was primary patency Secondary endpoints: Secondary patency, limb salvage, and survival Patency rates Primary patency 97.3% at 6 months and 90.2% at 3 year Primary patency was 78.5% at 7 years No difference for CLI vs IC (76.3% vs 79.4%; P = .20) at 7 years 11% target lesion revascularizations Procedure-related complications 11.5% during 7 years f/u Wicker et al. J Vasc Surg 2016;64:

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8 What about endovascular treatment options?

9 Anatomical Considerations
Frequent multi-vessel PAD involving inflow and outflow vessels Large vascular territory at risk Complex lesions Severe calcification Involvement of bifurcation Limited collateral supply Preservation of future access site for surgical and endovascular therapies

10 Endovascular Treatment Options
CONCERNS: Rate of complications Perforation Dissection Durability Risk of stent fracture In-Stent Restenosis Angioplasty Plain Drug coated balloon Atherectomy Rotational, directional, orbital, laser Stenting

11 Deformation of Femoral Vessels
Poulson et al J Vasc Surg 2018;67:607-13 Retrievable nitinol markers were deployed using a custom-made catheter system into 28 in situ FPAs of 14 human cadavers. Contrast-enhanced, thin-section computed tomography images were acquired with each limb in the standing (180 degrees), walking (110 degrees), sitting (90 degrees), and gardening (60 degrees) postures. Image segmentation and analysis allowed relative comparison of spatial locations of each intra-arterial marker to determine axial compression and bending using the arterial centerlines Poulson et al J Vasc Surg 2018;67:607-13

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13 Current Status of CFA Intervention
Limited data set Most data is retrospective Patient cohorts are heterogeneous No clearly defined endpoints No consensus guidelines CFA intervention is feasible and safe Long term surgical patency superior Short term endovascular morbidity superior

14 Endovascular Treatment of CFA Disease
Prospectively single-center database 360 consecutive percutaneous interventions of the CFA 77.9% IC and 22.1% CLI Outcomes: Procedural success, in-hospital complications 1-year patency, and target lesion revascularization rates 16.5% CLI (R-4) Bonvini et al. J Am Coll Cardiol 2011;58:792–8

15 CFA Interventions Lesions treated 26.9% isolated CFA
Method of Revascularization 98.6% PTA 36.9% PTA + Stent 6.9% Silverhawk Atherectomy 92.8% Procedural success 6.4% complications 1.7% Contralateral access site complications 1.7%Distal embolization 1.7% Thrombotic vascular events 1.4% Minor complications (i.e., AV fistula, non–flow limiting dissection) 5% complications required re-intervention Bonvini et al. J Am Coll Cardiol 2011;58:792–8

16 Patency 1 year primary patency 72.4% TLR 19.9% Percutaneous 14.9%
Surgical 5.0% In-hospital death 1.2% Restenosis (50%) rate at months 74/268 (27.6) Late restenosis (i.e., 18 months) 36/174 (20.7) Late TLR (i.e., 18 months) 34/174 (19.5) Percutaneous 24/174 (13.8) Surgical 10/174 (5.7) 1-yr ABI‡ Bonvini et al. J Am Coll Cardiol 2011;58:792–8

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18 Stenting of the CFA Procedural success 96% Mean follow-up of 24 months
53 patients (primary stenting approach) 68% IC and 32% CLI Single-center, nonrandomized, prospective study Primary end point: absence of binary restenosis Secondary end points Freedom from TLR and stent fracture rate Procedural success 96% Mean follow-up of 24 months Primary patency 92.5% Stent fracture rate at 1 year was 9% disabling intermittent claudication (n ¼ 36) or chronic critical limb ischemia (n ¼ 17 Thiney et al. Ann Vasc Surg 2015; 29: 960–967

19 Long Term Outcomes of CFA Stenting
N=40 limbs underwent stenting of CFA 70% IC and 30% CLI Mean follow-up was 64 months The mortality rate at 5 years was 38% Primary patency 79% In-stent restenosis rate was 28% PFA involvement was a predictor of ISR 1 stent fracture was noted at the first year follow-up without clinical consequence Freedom from target lesion revascularization and target extremity revascularization were 79% and 73%, respectively. Balloon expandable stents only used in Type III lesions (5 out of 13), the rest were self expanding Nasr et al. Ann Vasc Surg 2017; 40: 10–18

20 CFA Interventions with Atherectomy
PTA with provisional stenting vs atherectomy for CFA occlusive disease 50% to 79% CFA stenosis-- > PTA with PS > 80% CFA stenosis--> atherectomy (Jetstream/Pathway) and PTA 167 cases 55% IC and 45% CLI 68% PTA only 23% atherectomy +/- PTA 9% provisional stenting standardized treatment choices included primary PTA only, atherectomy (Jetstream/Pathway atherectomy, Boston Scientific) +/- PTA, and provisional stenting. In the entire population (167 patients), the atherectomy group had a greater degree of pretreatment lesion stenosis vs the PTA-only group, whereas no significance was found in runoff status between these groups. Disease extending into the proximal SFA or PFA was also treated at the time of the intervention. Distal embolic protection devices were not used in any of the cases. All patients were systemically anticoagulated during the procedure with intravenous heparin to achieve activated clotting times >275 seconds. After the procedure, patients were discharged home on a 3-month course of antiplatelet agents (aspirin 6 clopidogrel). Mehta et al. J Vasc Surg 2016;64:369-79

21 During long-term mean follow-up of 42.5 months
Primary Patency 1 year: PTA 78%, Ather 90% 2 year: PTA 70%, Ather 92% 5 year: PTA 60% During long-term mean follow-up of 42.5 months Only 9 % of all patients received stents CFA provisional stent group had a 100% primary patency P=0.04 during long-term mean follow-up of 42.5 months, the CFA provisional stent group had a 100% primary patency, which was significantly better than the primary patency in the CFA nonstent groups combined (77.0%; P ¼ .0424 Mehta et al. J Vasc Surg 2016;64:369-79

22 Outcomes with DEB in CFA
100 cases; retrospective review 40 patients with DEB angioplasty 60 patients with femoral CFE Technical success was 100% in all patients DEB had lower 1-year primary patency 75.0% vs 96.7%; P < .003 At 2-year primary patency 57.1% vs. 94.1%; P < .001 Kuo et al. J Vasc Surg 2019;69:141-7

23 Endarterectomy group more calcification, more CTO
DEB hostile groin

24 CFE: higher rate of transfusions : 76%; longer hospital days 11 vs 4

25 Atherectomy and DEB in CFA
30 consecutive patients treated using DA followed by DCB dilatation Provisional stenting was allowed in the case of a suboptimal result 6% IC and 94% CLI Procedural success was achieved in 100% Stenting was needed in 3 cases 10% Primary patency in 1 year 90% TLR 10% Cioppa et al. EuroIntervention 2017;12:

26 TECCO Trial 117 patients with de novo CFA lesions
87% IC and 13% CLI In type III lesions with occluded SFA, stent placed from CFA to PFA RCT of surgery vs. primary stenting Procedural success 100% vs 94.6% Primary outcome: morbidity and mortality at 30 days Primary patency rate, target lesion and extremity revascularization rates were not different in the 2 groups SE stents Balloon expandable for type III lesions involving the bifurcation In type III lesions, in case of occlusion of the superficial femoral artery, the superficial femoral artery was abandoned and a self-expandable stent was placed from the CFA into the deep femoral artery. Goueffic et al. J Am Coll Cardiol Intv 2017;10:1344–54

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28 Primary patency was equivalent HR 0.9, p=0.93
1 stent fracture at 2 years No clinical sx

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30 2018: Updated SCAI guidelines
Optimal strategy is not clear and remains at the discretion of the operator Feldman et al. Catheter Cardiovasc Interv 2018;92:124-40

31 Severity of PAD and Survival
Norgren, L. et al. JVS 2011;45(1) , S5 - S67

32 Summary: Clinical Applications
Surgical and Endovascular Treatments are appropriate in different patient populations Patient selection Short term patency may be appropriate and applicable to CLI patient subset with higher risk of perioperative complications -> endovascular treatment Long term patency preferred for IC patients -> surgical treatment Future RCTs needed Future studies Stent fractures


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