Treatment of superficial femoral artery occlusive disease

The aim of this paper was to compile a literature summary of current treatment modalities for the treatment of superficial femoral arterial (SFA) disease. The English-language literature was searched for studies describing the treatment of SFA occlusive disease using surgical bypass (vein or prosthetic), percutaneous bypass (stent-grafts), bare stents, percutaneous transluminal angioplasty (PTA), and subintimal angioplasty (SA). Inclusion criteria for articles were presentation of primary patency rates, a minimum study population of 10, and baseline characteristics of the study population. Average primary and secondary patency rates for each treatment modality were obtained by weighting the results of each trial by the number of limbs treated. All identified papers were included in the summary, regardless of the study inclusion/exclusion criteria, comorbidities, or patient population. Since the study conditions and patient populations varied widely, this is not intended to be a meta-analysis or for use in directly comparing the efficacy of different treatment modalities; rather, it is to provide general information on their performance under the reported conditions. One hundred and twelve studies met the inclusion criteria for the 6 treatment modalities identified. Compilation of the data revealed different patient populations for the different treatment modalities. For example, PTA was generally used to treat short, stenotic lesions, while endografts and SA were generally used for longer, total occlusions. For this reason, patency rates for the different treatment modalities cannot be directly compared.     

介入治疗股浅动脉硬化闭塞19例分析

目的 探讨股浅动脉硬化闭塞介入治疗的方法和疗效.方法 回顾性分析2005年1月至2008年8月介入治疗的19例(22条下肢)股浅动脉硬化闭塞症患者的临床资料.其中Fontaine Ⅱb期(中、重度间歇跛行)6条,Ⅲ期(静息痛)8条,Ⅳ期(组织缺损)8条(其中足部溃疡6条,足趾坏疽2条).股浅动脉病变的平均长度8.8 cm(5.0～13 cm).病变TASC分型B型4条,C型17条,D型1条.通过彩色血管超声和(或)动脉造影观察病变段动脉术前、术后的影像学改变分析支架通畅率,分析术前、术后临床症状的改善情况,以临床改善率和保肢率来评价临床疗效.结果 17条肢体浅动脉开通(手术成功率77.3%),其中单纯FTA 11例,PTA加支架成形6例,共置入自膨式镍钛合金支架8枚.2例中转旁路手术,3例放弃手术.17条肢体平均随访12.5个月(3～33个月).1例术后1个月死于心心肌梗塞;4条肢体术后3～6个月再闭塞.17条肢体介入手术后1年一期通畅率为76.4%. 结论介入治疗股浅动脉硬化闭寨症有较满意的近期和中期疗效.     

影响股浅动脉硬化闭塞症外科治疗预后的相关因素

目的 明确股胴动脉病变TASCⅡ分级、流出道评分、影响动脉硬化危险因素与外科治疗股浅动脉硬化闭塞症术后疗效的相关性.方法 回顾性分析2006年1月至2009年9月北京同仁医院对股胭动脉硬化闭塞症行股胭动脉段介入或手术治疗142例患者的临床资料.采用TASCⅡ分级标准对股胴动脉段病变分级;使用流出道评分标准对胫腓动脉进行膝下流出道评分.随访患者术后疗效,用Kaplan-Meier法计算一期通畅率,用COX回归分析病变TASCⅡ分级、流出道评分、各种动脉硬化危险因素与术后一期通畅率相关性.结果 本组142例(197条患肢).其中外科手术治疗50例(58条患肢);介入治疗99例(139条患肢).随访患者141例(196条患肢),随访率90.8%.术后随访时间1～26个月,中位随访时间13个月.经COX回归分析,术前股浅动脉病变TASCⅡ分级(RR=1.471,P=0.012)、流出道评分(RR=1.190,P=0.004)、2型糖尿病(RR=2.320,P=0.019)为影响外科治疗股浅动脉病变术后一期通畅率的因素. 结论术前TASCⅡ分级级别较高、流出道评分分值较高及患有2型糖尿病的患者,股浅动脉病变术后一期通畅率不佳.     

Stent placement for superficial femoral arterial occlusive disease in high-risk patients: Preliminary results

Purpose  To report the preliminary results of primary stenting of the superficial femoral artery (SFA) in high-risk patients with symptomatic SFA occlusive disease. Methods  Between February 2005 and April 2007, a collective 30 lower limbs in 28 high-risk patients with SFA occlusive disease were treated by primary stenting. Hemodynamic improvement was assessed by ankle brachial pressure index (ABI), before and after the procedure. Primary and primary-assisted patency and limb salvage were measured in concordance with the Society for Vascular Surgery guidelines. Results  The technical success rate was 97%. The average ABI before and after stent placement increased significantly, from 0.41 ± 0.33 to 0.82 ± 0.20 (P < 0.001). The primary and primary-assisted patency rates were 86% and 90% at 6 months, 86% and 90% at 12 months, and 68% and 90% at 24 months, respectively. The limb salvage rate was 92% at 6, 12, and 24 months and the survival rate was 95% at 6, 12, and 24 months. Conclusion  Our results suggest that the primary stenting of SFA lesions is a feasible, safe, and effective procedure for high-risk patients with SFA occlusive disease.     

Noninvasive measurement of femoral artery pressure for evaluating aortoiliac occlusive disease

Femoral systolic pressures measured by a compression technique (FSCP), were compared with proximal thigh systolic pressures (PTSP), for evaluation of aortoiliac occlusive disease. In phase I FSCP were measured by compressing the artery with a pressure cuff rolled into a cylinder and using disappearance of the profunda femoris Doppler signal (FSCP-D), or flattening of thigh plethysmographic waveforms (FSCP-P), as sensors. In normal extremities the compression techniques yielded false high values. The mean ratio of FSCP-D to brachial systolic pressure, FSCP-D/BSP, was 1.25 +/- 0.06 and the mean FSCP-P/BSP was 1.37 +/- 0.15, a value approximately equal to the mean PTSP/BSP, 1.38 +/- 0.20. In patients with aortoiliac occlusive disease linear regression analysis revealed a good correlation between FSCP-D/BSP and direct intraoperative measurements of femoral/aortic systolic pressure, FSP/ASP, (R = 0.79 and R2 = 0.63), a fair correlation between FSCP-P/BSP and FSP/ASP (R = 0.49, R2 = 0.24) but a poor correlation between PTSP/BSP and FSP/ASP (R = 0.35, R2 = 0.12). In phase II studies a soft bladder was used for arterial compression. In normal extremities the mean FSCP-D/BSP was 1.07 +/- 0.06, close to the predicted normal value of 1.00. In a second group of patients with occlusive disease a better correlation was observed between values of FSCP-D/BSP and FSP/ASP (R = 0.91, R2 = 0.82), than any of the correlations of noninvasive measurements with direct intraoperative values of FSP/ASP obtained in the first phase of the study.     

Aortoiliac reconstruction in patients with combined iliac and superficial femoral arterial occlusion

Despite revascularization of the common femoral--profunda femoris system, many patients fail to obtain satisfactory relief from claudication or rest pain. Clinical observations were compared with objective physiological data in 54 technically successful aortoiliofemoral reconstructions for multilevel disease. Nine of 28 operations (32%) for claudication and five of 26 operations (19%) for ischemia at rest had poor results. While the average ankle pressure index (API = ankle blood pressure/arm blood pressure) rose from 0.52 +/- 0.03 (SEM) to 0.81 +/- 0.03 in limbs treated successfully for claudication, it changed insignificantly in those with an unsuccessful result (0.58 +/- 0.04 to 0.61 +/- 0.04). When ischemic symptoms were relieved, API rose from 0.23 +/- 0.04 to 0.55 +/- 0.03 but increased only from 0.22 +/- 0.09 to 0.40 +/- 0.02 in limbs with insufficient improvement. Preoperative thigh pressure index (TPI) in claudicating limbs with poor results (0.96 +/- 0.05) differed little from that in limbs with good results (0.92 +/- 0.05); nor was the TPI of ischemic limbs with poor results (0.83 +/- 0.13) significantly greater than that in limbs with good results (0.60 +/- 0.05). Neither the TPI nor the thigh to ankle pressure gradient was of value in predicting which extremities would respond poorly to aortoiliofemoral reconstruction.     

Current therapeutic options in the management of superficial femoral artery occlusive disease

The management of superficial femoral artery occlusive disease remains challenging for vascular surgeons. Despite the advances and dramatic changes we have seen in modern practice with the development and introduction of new endovascular techniques, long-term results with these interventions remain disappointing when compared to the "gold standard" of a vein bypass with a good run-off. Furthermore, there is little Level 1 evidence to guide us with regards to the best treatment strategy. In this article, we review some of the currently available open surgical and endovascular options for the management of superficial femoral artery disease.     

Semiclosed endarterectomy for long superficial femoral artery atherosclerotic occlusive disease. One-year angiographic results

BACKGROUND: The anatomic results of endarterectomy of long occlusive lesions in the superficial femoral artery (SFA) are required for reconsidering this procedure and comparing the results with those of newly developed endovascular techniques. We designed a prospective study to determine the arteriographic findings one year after a successful semiclosed endarterectomy of long occlusive lesions in the SFA. METHODS: From January 1995 until July 1996, an endarterectomy in the SFA was attempted in 12 successive patients and was successfully performed in 10 patients (6 men and 4 women), with an average age of 73 years (range 66 to 90 years). Indications for successfully performed procedures were claudication in 6, non healing ulcer in 2, local gangrene in 2 patients. The mean length of the occlusion was 17 cm (12-33). Six patients had poor run-off with 0 to 1 patent tibial artery. The mean length of the endarterectomised segment was 31 cm (27-39). An angioscopy and an angiography were performed in all procedures. There were no postoperative complications. All patients had an angiography at 12 months or before because of ipsilateral disease. Primary angiographic patency was defined as patency of the treated artery with stenosis of less than 30%. A short stenosis was defined as <5 cm. These lesions were an indication of percutaneous balloon angioplasty (PTA) and the final results were listed as secondary patency. RESULTS: Angiography revealed 3 patent arteries, 5 short stenosis, 2 long stenosis and no occlusions. The primary patency rate was 30% at 12 months. The secondary patency was 80% with a mean follow-up of 19 months (ranging from 13 to 25 months). The mortality and amputation rate at 12 months was nil. CONCLUSIONS: Despite a modern intraoperative control, there was a high incidence of restenosis after semiclosed endarterectomy performed for long occlusive lesions of the SFA. As a result of a close surveillance and PTA, the secondary patency at one year was good. Before a widespread use of newly developed endovascular techniques, comparative patency studies with the mere endarterectomy should be performed. Endarterectomy followed by a PTA in cases of restenosis, is an alternative to bypass when the vein is not available.     

Delayed recanalization angioplasty after traumatic occlusion of the superficial femoral and popliteal artery

The management of patients presenting with limb-threatening ischemia after lower limb trauma poses particular demands on vascular surgeons. We describe two patients with lower limb arterial occlusions who presented with limb-threatening ischemia 8 years and 3 years after trauma to the lower limb. They were successfully managed by recanalization angioplasty, with a good early clinical outcome after 5 months and 3 months, respectively. Recanalization angioplasty is a useful adjunct in the management of ischemic limbs after trauma.     

Aortofemoral dacron reconstruction for aorto-iliac occlusive disease: a 25-year survey.

The authors present a consecutive series of 869 patients, who received an aorto(bi)femoral Dacron graft for occlusive disease between 1963 and 1988. The operative indications were grade 1 disease (n = 371), grade 2 disease (n = 408) or grade 3 disease (n = 90). The operative mortality was 4.5% and remained stable over the years of the study. The median survival was 8.2 years and 25% of the patients survived for more than 15 years. Late patency decreased to 74% and 70% after 10 and 15 years, respectively. Fifty-six patients underwent a major amputation in the long run. The amputation rate increased to 3, 8.6 and 12.1%, respectively for grade 1, grade 2 and grade 3 disease. Satisfactory functional results were obtained by 51% and 40% of the patients after 10 and 15 years, respectively. By means of secondary and tertiary operations this increased to 70% and 61%. Long term functional results were primarily dependent on smoking habits postoperatively, the date of operation and the presence of concomitant femoro-popliteal occlusive disease.     

The results of superficial femoral, popliteal, and tibial artery stenting for peripheral vascular occlusive disease

The purpose of this study was to evaluate the patentcy rates and physiological effectiveness of angioplasty and stenting as a primary therapy for superficial femoral (SFA), popliteal (POP), and tibial (TIB) arterial occlusive disease. Seventy-eight patients had stents placed in the infra-inguinal vessels between January 1, 2001, and July 31, 2004. We collected data on patient demographics, symptoms, as well as pre- and postprocedure ankle-brachial index (ABI) and angiographic findings. Patency rates at 6 months, 12 months, and 24 months were analyzed by life table methods. Thirty-one men and 47 women had a mean age of 68 years (range 36-94 years). Risk factors included diabetes in 50 per cent, hypertension in 79 per cent, smoking in 41 per cent, and end-stage renal disease in 10 per cent. The indications for intervention were claudication in 52 per cent and limb salvage in 48 per cent of patients. Stents were placed in the SFA in 54 patients (69%), in the POP in 15 patients (18%), and in the TIB artery in 6 patients (8%). Average follow-up was 11.2 months. The mean postprocedural increase in ABI was 0.29. The 6-month, 1-year, and 2-year primary patency rates were 83 per cent, 58 per cent, and 47 per cent, respectively. Limb salvage was achieved in 66 per cent of patients treated for limb-threatening ischemia. There was one major and three minor complications. Stenting of the infra-inguinal vessels has a low morbidity, high success rate, and acceptable patency and limb-salvage rates.