Treating femoropopliteal disease: established and emerging technologies

Abstract

The femoropopliteal artery is the most common site of disease in patients with peripheral arterial disease and presents some of the greatest challenges for interventional radiology. Many patients can be managed with medical treatment combined with supervised exercise alone. However, a significant proportion, especially those suffering from severe intermittent claudication or critical limb ischemia, will require some form of endovascular or surgical revascularization procedure. During the past few years an endovascular-first approach has gained support from all vascular specialties. Today, even complex lesions can be treated successfully with an endovascular approach. Unfortunately, the unique bio-mechanical properties of this vascular segment have limited long-term patency rates and clinical value of the endovascular options. In this review, the authors discuss the methods and techniques for treatment of femoropopliteal lesions and review the current evidence for commercially available devices on patency outcomes following successful recanalization.

Keywords: angioplasty; balloon; covered stent; drug-eluting; femoropopliteal; interventional radiology; paclitaxel-coated; restenosis; severe leg ischemia; stent; subintimal.

Figure 1

Complex femoropopliteal artery recanalization. (A, B) Baseline antegrade angiogram in a 67-year-old man with short distance claudication and occasional rest pain during the night shows a long-segment TASC D flush total chronic occlusion of the superficial femoral and proximal popliteal artery (arrow). The procedure was performed with carbon-dioxide imaging because of impaired renal function. (C, D) Subintimal recanalization with the Bolia loop wire technique and targeted re-entry at the level of P2 segment with the OUTBACK catheter (Cordis) (arrow).

Figure 2

Final result. Completion angiogram (right panel) shows a widely patent femoropopliteal artery after long 6-mm balloon angioplasty and placement of a new generation interwoven nitinol metal stent (SUPERA, Abbott, Abbott Vascular, Illinois; left panel) (arrow). The whole procedure was completed with the use of a total volume of 400 mL CO₂.

Figure 3

Popliteal stenting case. (A) Baseline antegrade angiography in a 70-year-old woman with relatively recent deterioration (6 weeks ago) of her symptoms of lifestyle limiting claudication at the level of the calf. Angiogram shows an 8-cm long total occlusion of the distal SFA and P1 segment of the popliteal artery (occlusion between open arrows) (B) The lesion was treated with primary stenting with a hybrid heparin-bonded nitinol ring stent (TIGRIS, Gore Medical; white arrows), as it was felt that there was a high risk of distal embolization because the wire crossed the lesion very easily. (C) Balloon post-dilation of the stent, and (D) completion angiogram shows a widely patent artery.

Figure 4

Dynamic stent imaging Lateral knee-flexion angiogram (right panel) of the TIGRIS stent (white arrows; left panel) shows good stent conformability with the demanding biomechanical environment of the popliteal anatomy without any kinks or functional stenosis.

Figure 5

Network meta-analysis. Horizontal bars denote the cumulative rank probabilities of being the best treatment for the various different devices analyzed in a recently published mixed treatment comparison meta-analysis. Paclitaxel balloons and stents ranked as the top treatments, as they were both associated with the least vascular restenosis and the lowest need for repeat procedures.