superficial femoral artery disease: simulation training curriculum

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Superficial Femoral Artery Disease:

Simulation TrainingCurriculum

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Superficial Femoral Arterial DiseaseSuperficial Femoral Arterial Disease

Prevalence Clinical Presentation Diagnosis Indications Technical Issues Treatment Options - PTA

- Surgical Complications Prognosis

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SFA disease: Responsible for > 50% of PAD Cases

• One of the longest vessels in

the body

• Torsion/compression/flexion/

extension by the largest

muscle group

• Two flexion points

• Few collateral sources

• Occlusions predominate

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• Most common in men than women

• Most common in older patients with concomitant

coronary disease

• Strong relationship between increased tortuosity

and disturbed hemodynamic patterns in regions

of the SFA

Predilection for the region of the adductor canal 1

1. Wood et al J Appl Physiol 2006 (6)

Superficial Femoral Arterial DiseaseSuperficial Femoral Arterial Disease

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Extension / Contraction 1.

Torsion

2.

Compression

3.Flexion 4.

Forces Exerted in SFA

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• Isolated SFA disease predicts low amputation risk (0-1%) without surgical revascularization 1

1. Hertzer NR Circulation 1991; 83(Suppl.1):I-12 – I-19

Superficial Femoral Arterial DiseaseSuperficial Femoral Arterial Disease

DISEASE PROGRESSION •Other arterial segments involved

•Increasing risk of critical limb ischemia

•Cumulative smoking history •Contralateral superficial femoral artery occlusion

• Presence of diabetes

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Superficial Femoral Arterial DiseaseSuperficial Femoral Arterial Disease

Prevalence Clinical presentation Diagnosis Indications Technical Issues Treatment Options - PTA

- Surgical Complications Prognosis

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Clinical Presentation

• Claudication

• Critical limb ischemia (less common)

– The presence of the Profunda Femoris

Artery, the main nutritive artery of the

thigh, protects patients with SFA

occlusion from critical limb ischemia

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Morphological Stratification of Femoropopliteal Lesions

TASC Type A

• Single stenosis less than 3 cm of the superficial femoral artery or popliteal artery

TASC Type B

• Single stenosis 3 to 10 cm in length, not involving the distal popliteal artery

• Heavily calcified stenoses up to 3 cm in length

• Multiple lesions, each less than 3 cm (stenoses or occlusions)

• Single or multiple lesions in the absence of continuous tibial runoff to improve inflow for distal surgical bypass

TASC Type C

• Single stenosis or occlusion longer than 5 cm

• Multiple stenoses or occlusions, each 3 to 5 cm in length, with or without heavy calcification

TASC Type D

• Complete common femoral artery or superficial femoral artery occlusions or complete popliteal and proximal trifurcation occlusions

ACC/AHA Guidelines

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Superficial Femoral Arterial DiseaseSuperficial Femoral Arterial Disease

Prevalence Diagnosis Indications Technical Issues Treatment Options - PTA

- Surgical Complications Prognosis

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• Clinical evaluation

Superficial Femoral Arterial Disease:Superficial Femoral Arterial Disease:DiagnosisDiagnosis

Stevens et al JAMA 2006;295(5):584

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Diagnostic Methods

• Ankle-and Toes – Brachial Indices, segmental pressure examination

• Pulse volume recording

• Continuous wave doppler ultrasound

• Treadmill exercise testing with and without ABI assessments and 6 minute walk test

• Duplex ultrasound

• Computed tomographic angiography

• Magnetic resonance angiography

• Contrast angiography

Hirsh et al Circulation 2006; 113(11): e463-654ACC/AHA Guidelines

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Stenosis in the superficial femoral artery visualized satisfactorily in the color mode

Diagnostic Methods: Duplex Ultrasound

Ramaswami et al J Endovasc Surg. 1995; 2(1): 27-35

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Diagnostic Methods: MRA

Lower extremity MRA showing severe stenoses in left superficial femoral artery and smaller stenoses in right superficial femoral artery.

Cochrane J Radiology Rounds MGH 2004;2(11)

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Diagnostic Methods: CTA

Coronal multi–detector row

CT angiography : Occlusion of the right superficial femoral artery (thick arrow)

• The diagnostic accuracy of CT angiography has been proved superior to that of conventional arteriography in several applications

• CT angiography is substantially less invasive and less expensive, and it allows three-dimensional visualization from any angle and in any direction, which cannot be achieved with projection techniques such as DSA

Catalano et al Radiology 2004;231:555-563

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Digital subtraction angiography (DSA) shows A the occlusion of the left common iliac artery and external iliac artery, long occlusion of both superficial femoral arteries (SFAs) with no visible stump on the left, and B restoration of both distal SFAs through collaterals (arrows)

Diagnostic Methods: DSA

Yılmaz et al Eur Radiol. 2002;12(4): 911-4

A B

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Superficial Femoral Arterial DiseaseSuperficial Femoral Arterial Disease

Prevalence Diagnosis Technical Issues

Treatment Options - Medical

- PTA - Surgical

Complications Prognosis

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Superficial Femoral Artery Technical Approach

• Diagnostic Arteriogram: Showing inflow and outflow of the target lesion

• Run-off angiography to visualize the lower extremity circulation

Grossmans “Catheterization” 7th Ed. pg. 254-280

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Vascular Access• Antegrade common femoral artery puncture :

– Most common

• Contralateral retrograde access over the aortic bifurcation– Advantages:

• The ability to image the common femoral and its bifurcation• The ability to treat iliac and infrainguinal disease in the same timing

– Disadvantages:• Working from a distance with exchange-length wires and balloons

• Retrograde popliteal artery access– Rare cases where the antegrade or contralateral approach fails to

traverse an occluded segment– In the event that a subintimal channel has been created

• Brachial access– Provides better radiation protection, since one is working far from the

actual target site, but requires the use of lengthy wires and devices

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Superficial Femoral ArteryAnticoagulation

• Aspirin (325 mg) once a day several days prior the procedure

• After access has been obtained and prior to intervention: 2500 – 5000 international units of heparin

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Superficial Femoral Arterial DiseaseSuperficial Femoral Arterial Disease

Prevalence Diagnosis

Technical Issues Treatment Options

- Medical - PTA

- Surgical Complications Prognosis

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Superficial Femoral Arterial Disease: Superficial Femoral Arterial Disease: Treatment Treatment

Patients with Claudication

• Aggressive risk factor modification

• Exercise program

Patients with Critical Limb Ischemia

• Revascularization

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• PTA is the preferred initial treatment in patients with disabling claudication 1

• In patients with critical leg ischemia, PTA is better for the treatment of femoropopliteal stenosis, whereas femoropopliteal occlusion is best managed with bypass grafting 1

• Percutaneous transluminal angioplasty (PTA) has been recommended only for short lesions of the superficial femoral artery 2

1. Hunink et al JAMA 1995; 274(2) 165-1712. Dormandy JA, Rutherford B J Vasc Surgery 2000; 31:S1-S296

Superficial Femoral Arterial Disease:Superficial Femoral Arterial Disease:Angioplasty

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Superficial Femoral Arterial Disease:Superficial Femoral Arterial Disease:Angioplasty

• Low procedural morbidity and mortality

• Reduced costs

• Shortened hospital stay

• Preserves collaterals so that even if the angioplasty site occludes, symptoms might not return

• Patients who are expected to live for less than 1–2 years and have significant comorbidity should probably, when possible, be offered angioplasty first.

If the procedure fails, the patient may not be disadvantaged in the

short term and can go on to have surgery if regarded as appropriate

Adam et al Lancet 2005;366:1925-1934.

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Adjunct Therapies

• Stents

• Directional atherectomy

• Rotational atherectomy

• Laser angioplasty

• Intra-arterial radiation

• Cryotherapy

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Superficial Femoral Arterial Disease:Superficial Femoral Arterial Disease:Stenting

• Is recommended only as a bailout procedure after technical failure of angioplasty

– Flow limiting dissections

– Residual pressure gradient >15mmHg

– Remaining stenosis >30%

– An elastic recoil as well as failure to maintain initial patency

Heuser R, Biamino G. Peripheral Vasc Stenting.2nd Ed. 91-108

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The Palmaz TM stent

•High radial force: valuable in highly calcified lesions

•Precise placement

•Disadvantage: significant stiffness

Superficial Femoral Arterial Disease:Superficial Femoral Arterial Disease:

Strecker TM stents

• Very flexible: Allows for a contralateral placement using crossover approach

• Disadvantage: deformability by extrinsic compression, which can lead to restenosis and reocclusion in the femoropopliteal tract

Balloon Expandable Stents : Not indicated in the femoropopliteal region, with exception of short, very calcified lesions less than 2 cm in length.

Heuser R, Biamino G. Peripheral Vasc Stenting.2nd Ed. 91-108

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• Stents of choice for implantation in the SFA• Advantages over balloon expandable stents:

– Higher flexibility – Recoil tendency after external deformation

The Wallstent• Difficult exact placement: shortening up to one-thirdNinitol Stents • Implantation more precise foreshortening (Max

5%)• Superior accommodation to different artery diameters

Superficial Femoral Arterial Disease:Superficial Femoral Arterial Disease:Stenting

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Duplex-guided Balloon Angioplasty and Stenting

• Duplex methodology can be used to map the arterial disease process and to guide wires, sheaths, balloons, and stents for the treatment of superficial femoral

• Effective in achieving excellent anatomic and hemodynamic improvement regardless of the extent of the stenotic lesion

• Benefic in patients severely allergic to contrast material or those with renal insufficiency

Power Doppler image of severe (81%) superficial femoral artery stenosis. The hemodynamic significance of this lesion was confirmed by a peak systolic velocity of 388 cm/s with marked spectral broadening.

Ascher et al J Vasc Surgery 2005; 42(6): 1108-1113

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Directional Atherectomy

Directional atherectomy of right superficial femoral artery. A. Angiography via antegrade punctureinto right common femoral artery demonstartes high-grade stenosis in proximal SFA, not favorable for balloon angioplasty owing to ostial location/eccentricity. B. An 8Fr directional atherectomy catheter introduced via sheat, which is then pulled back to common femoral artery. C. Angiography following DA demonstrates excellent result

Grossmans “Catheterization” 7th Ed. pg. 593-595.

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Excimer laser Atherectomy

Excimer laser atherectomy of peripheral arteries has been practiced commercially in Europe since 1994 and has been shown to be a useful adjunct for the treatment of long superficial femoral artery (SFA) occlusions

Scheinert et al J Endovasc Ther. 2001;8:156–166

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• When PTA has been attempted for more diffuse disease and long occlusions, limb salvage rates are considerably lower

Laird et al J Endovasc Ther. 2006 Feb;13(1):1-11

Superficial Femoral Arterial Disease:Superficial Femoral Arterial Disease:

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A) A rather extreme case of severe ulceration with associated infection on the bottom of the foot prior to intervention. (B) At 6 months after treatment with excimer laser atherectomy , healing is nearly complete

Laird et al J Endovasc Ther. 2006 Feb;13(1):1-11

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Surgery

• Bypass surgery with venous grafts

– Good long-term anatomical patency

– Clinical durability

• Bypass surgery vs. angioplasty :

– Angioplasty also seems to be a much less expensive option than surgery, at least in the short term

– The rates of amputation – free survival after surgery and balloon angioplasty are similar for the first two years.

Adam et al Lancet 2005;366:1925-1934.

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Amputation-free survival after bypass surgery and balloon angioplasty

Adam et al Lancet 2005;366:1925-1934.

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All-cause mortality after bypass surgery and balloon angioplasty

Adam et al Lancet 2005;366:1925-1934.

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Poor Surgical Candidates

• Severe distal tibial occlusive disease

• Inadequate distal targets for revascularization,

• Absent venous conduit, or

• Significant medical or cardiac comorbidities

rendering them at high risk for complications

from surgery.

Laird et al J Endovasc Ther. 2006 Feb;13(1):1-11

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Superficial Femoral Arterial DiseaseSuperficial Femoral Arterial Disease

Prevalence Diagnosis

Technical IssuesTreatment Options - Medical

- PTA - Surgical

Complications Prognosis

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Complications

• Acute or subacute thrombosis

• Restenosis

• Dissection

• Distal embolization

• Perforation

• Hematoma

• Stent fractures

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Superficial Femoral Arterial DiseaseSuperficial Femoral Arterial Disease

Prevalence Diagnosis

Technical IssuesTreatment Options - Medical

- PTA - Surgical

Complications Prognosis

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Unfavorable Predictors

• Type of lesion (occlusion)• Long or eccentric lesions• Diffuse atherosclerosis • Limb-threatening ischemia • Poor initial post-PTA appearance • Diabetes mellitus• Congestive heart failure• Poor distal outflow

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Favorable Predictors

• Higher preoperative ABI

• Performance of angioplasty

• Type of lesion (stenosis)

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Percutaneous angioplasty or stenting of the SFA 1986-2004

Surowiec SM. J Vasc Surg. 2005;41(2):269-78

0

10

20

30

40

50

60

70

80

12 24 36 48 60

Prim

ary

Pat

ency

Rat

es (

%)

Months

380 limbs66% IC

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SFA Patency RatesMeta-analysis 1993-2000

0

10

20

30

40

50

60

70

PTA Stent

ICCLI

3-year Primary Patency Rates

Roehring JVS 2005

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Rates of Restenosis on Angiography

0

10

20

30

40

50

60

Intention to TreatAnalysis

As Treated Analysis

Res

teno

sis

Rat

e %

43%(23 of 53)

24%(12 of 51)

50%(18 of 36)

25%(17 of 68)

P=0.05 P=0.02

Angiplasty Stenting

Schillinger et al N Eng J Med 2006;354:1879-1888

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Rates of Restenosis on Duplex Ultrasonography

0

10

20

30

40

50

60

70

3 Mo 6 Mo 12 Mo

Res

teno

sis

Rat

e %

23%(12 of 53)

14%(7 of 51)

45%(24 of 53)

25%(13 of 51)

P=0.36 P=0.06

Angioplasty Stenting

Schillinger et al N Eng J Med 2006;354:1879-1888

63%(33 of 52)

37%(18 of 49)

P=0.01

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Clinical Outcomes Angioplasty Vs Ninitol Stent Group

0

50

100

150

200

250

300

350

400

450

Baseline 24 Hr 3 Mo 6 Mo 12 Mo

Angioplasty

Stenting

P=0.25 P=0.68 P=0.50 P=0.04P=0.04

Max

imu

m W

alki

ng

Dis

tan

ce (

m)

Schillinger et al N Eng J Med 2006;354:1879-1888

48Surowiec SM. J Vasc Surg. 2005;41(2):269-78

SFA PTA or Stenting 1986-2004Comparison with Venous and Prosthetic Bypass

TASCLESION

TASCLESION

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Stent or PTA of the SFA 1986-2004:Freedom from symptom recurrence

Surowiec SM. J Vasc Surg. 2005;41(2):269-78

TASC lesion

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Durability of Endovascular Intervention for Iliac and Femoropopliteal Disease

0 10 20 30 40 50 60 70 80 90 100

Iliac Stent

Iliac PTA + Stent

Iliac Occl

Iliac Occl + Stent

F-P PTA

F-P PTA + Stent

1 year

3 year

5 year

TASC Working Group , J Vasc Surg 2000;31:S1-S296

Primary Patency at 1, 3, 5, Years

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Femoro-popliteal Bypass Graft Occlusion: Dutch BOA Study

Smeets et al Eur J Vasc Endovasc Surg 2005; 30(6):604-9

0

5

10

15

20

25

30

35

40

Venous Conduit Prosthetic Conduit

Fem-pop

Femoro-distal

Multicenter, randomized comparison of coumadin vs. ASA for prevention of graft occlusion2690 patients with mean follow-up of 21 months: 51% claudicants, 48% with CLI

Conduits: 64% venous 36% prosthetic conduits

52Schouten et al Eur J Vasc Endovasc Surg. 2005; 29:457-62

Durability of Surgical Bypass:Multicenter Randomized VASCAN Trial

0

10

20

30

40

50

60

70

80

12 months 24 months 36 months

End-to-end

End-to-side

Pri

ma

ry p

ate

ncy

ra

tes

(%

)

P=0.26

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Proximal SFA occlusion

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Excimer Laser

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After Stenting