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Endovascular interventions, surgery: Both options for common femoral artery

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SAN DIEGO — A history of data backs the use of surgery in patients with common femoral artery lesions, but as more studies emerge, endovascular therapy also is carving out a space, according to two speakers at TCT 2018. George S. Chrysant, MD, from the department of cardiology at INTEGRIS Heart Hospital in Oklahoma City, and Virendra I. Patel, MD, from the department of surgery at Columbia University Medical Center, squared off against each other in a debate about whether common femoral artery lesions can be treated with endovascular techniques as opposed to always being treated surgically, but they ended up coming to the same conclusion: Results from current studies show that both treatment modalities are safe and effective in this patient population.

Understanding lesions

Chrysant, who was tasked with arguing that endovascular therapy is an acceptable treatment for common femoral artery lesions, said it is important to understand the anatomy before considering a treatment modality because these lesions are not all the same and the risk of compromising the profunda is greater in some situations than others.

“Whether you want to use the coronary classification as applied to the common femoral artery or this alternative method, it is very important to identify where the disease is and think a couple of steps ahead in terms of what could potentially require a bailout,” he said.

A review of the data shows that patients with common femoral artery lesions, including more complex lesions, fare well after percutaneous transluminal angioplasty alone or angioplasty combined with atherectomy in terms of restenosis, primary and secondary patency, and length of hospital stay, according to Chrysant. Additionally, some studies have demonstrated no significant differences in outcomes for patients undergoing endovascular treatment, such as stents or drug-coated balloons, when compared with surgery. Others have shown that outcomes favored endovascular treatment, either alone or in combination, over surgery, he added.

“In conclusion, I would say that endovascular therapy can be performed safely and reproducibly. There are data, and more in press as we speak, looking at all sorts of combination therapy, but you need to understand the lesion types and understand when caution should be applied,” Chrysant said. “And for people early in their careers, there is nothing wrong with referring a patient for an endarterectomy. You’ll be perceived as a person with good judgment. Don’t be afraid of surgery.”

In support of surgery

Unlike endovascular therapy, surgery has long been a treatment for patients with common femoral artery lesions. Consequently, a wealth of data back its use, according to Patel, who argued in favor of surgery only in this patient population.

Technical success is high with surgery, Patel said. Several single-center experiences also demonstrate excellent primary and secondary patency in the long term. Additionally, hospital stays are not lengthy and the rate of morbidity, primarily due to groin infections, is low.

“Endarterectomy is historically a safe operation. However, there are high-risk patients, including patients with functional independence, those with significant obesity — which predisposes them to groin wound infections — and those with steroid usage, and diabetes,” Patel said. “Therefore, while endarterectomy is the gold standard, there is interest in endovascular interventions, and they do have benefit, especially in these high-risk populations.”

Nevertheless, endovascular interventions also have drawbacks for lesions in arteries with high inflexion, heavy calcification or bifurcation, Patel said.

Even so, endovascular interventions are “coming into vogue” in this area, he said, with a number of single-center studies demonstrating positive results. Technical success has been high, mortality has been excellent, and vascular and thrombotic complication rates have been low, according to Patel. The major issues with peripheral interventions are higher rates of restenosis and target lesion revascularization, as demonstrated in some of these studies. One trial even showed worse outcomes with endovascular intervention compared with surgery.

In light of the data overall, though, he said that he believes “there is promise for both treatment modalities. ... We in the surgical community are sort of embracing common femoral interventions.” – by Melissa Foster

Reference:

Chrysant GS, et al. Session I. SFA and Popliteal Therapies. Presented at: TCT Scientific Symposium; Sept. 21-25, 2018; San Diego.

Disclosures: Chrysant reports he receives consultant fees from Abbott Vascular, Boston Scientific, Medtronic and Philips. Patel reports no relevant financial disclosures.