When to Use Adjunctive Therapy for Common Femoral Artery Revascularization in Non-Surgical Patients

Disclosure: Dr. Mustapha reports he is a consultant for Bard, Covidien, Cordis, CSI, Spectranetics, Boston Scientific, Cook, and Terumo. Dr. Craig Walker reports he is a consultant for Boston Scientific, Cardiva Medical, Cook Medical, Lake Regional, Medtronic, and Spectranetics. He proctors PVD training courses for Abbott, Bard, Boston Scientific, Spectranetics, and Trireme. He is a stockholder in Cardiva Medical, Cardioprolific, Spectranetics, and Vasamed. He is on the medical/scientific boards of Abbott, CR Bard, Boston Scientific, and Spectranetics. He is on the speaker’s bureau for Abbott, Arbor Pharmaceuticals, AstraZeneca, Atrium Medical, Boehringer-Ingelheim, Bristol-Myers Squibb/Sanofi Pharmaceutical, Cardiva Medical, Cook Medical, Cordis, DSI/Lilly, Forest Pharmaceuticals, PamLabs, Pfizer, Spectranetics, and Takeda. 

The authors can be contacted via Dr. J.A. Mustapha at jihadmustapha@aol.com.

J.A. Mustapha, MD: When you think of common femoral revascularization, what method of therapy comes to mind immediately, endovascular or surgical?

Craig M. Walker, MD: In general, I think of surgical endarterectomy when I think of common femoral artery (CFA) disease. Isolated CFA disease is rare and is often the result of prior injury or vascular closure tools. Involvement of the profunda and superficial femoral artery (SFA) is common. The CFA is an important site for vascular access as well as an important site for bypass surgical procedures; therefore, typically, stenting is not considered an ideal treatment, although several reports have shown excellent stent patency. There are cases, however, where the common femoral artery is fairly long and the disease is 3 or more cm above the bifurcation of the SFA/profunda where a stent can be utilized, and access and surgical options preserved, leaving 2-3cm of untreated CFA where stenting is a reasonable option. Atherectomy is another option that may allow interventional treatment while preserving access and bypass options, particularly when coupled with recently approved drug-eluting balloon therapies. If I note that a sheath is occlusive at the entry site when I am attempting contralateral treatment that may be prolonged, I will occasionally dilate the femoral artery entry site with the sheath in place from another access to lessen risk of vascular thrombosis. There are occasionally cases where there have been multiple surgical revisions or active infection where an interventional approach may be preferable. Despite these caveats, common femoral endarterectomy with patch has been a durable and proven low-risk option for treating these patients.   

J. Mustapha: Do you always place a wire in the SFA and the profunda during common femoral artery revascularization?

C. Walker: I do not. If the disease is well above the bifurcation, I typically do not place 2 wires. If there is SFA and profunda involvement, I will routinely place 2 wires before balloon angioplasty in case there is plaque shift. Depending on which form of atherectomy I am considering, I might place 2 wires (some types of atherectomy may injure the other wire).

J. Mustapha: What form of atherectomy do you think is the best debulking agent for the CFA?  

C. Walker: I like directional atherectomy, as I am typically treating only a short segment of disease and I can create a large channel with low risk of plaque shift. I am, of course, concerned about the risk of distal emboli and the inability to place filters in more 

than one vessel.

J. Mustapha:  If you were to stent a CFA, what would be the most functional stent for this region? 

C. Walker: I have historically liked the Supera stent (Abbott Vascular), as it is flexible, fracture resistant, and has great radial strength. Unfortunately, at present, the largest available diameter is the 6.5mm stent, which may be too small for some CFAs. I think that most of the newer generation stents will also maintain their integrity in this area and drug elution may be useful here, particularly in cases of multiple restenosis.  

J. Mustapha: How do you think the era of drug-coated balloons will shift the status quo of CFA therapy?

C. Walker: I am hopeful that this will have a major impact, but I am not certain it will be standalone therapy.  These vessels are often very calcified, and elastic recoil and dissection are common. In addition, the calcium may inhibit drug uptake.