What is the management of 60% calcification in the right common femoral artery?

From the Guidelines

Management of a 60% calcified stenosis in the right common femoral artery typically requires a combination of medical therapy and consideration for revascularization, with surgical endarterectomy being the preferred treatment option due to superior long-term patency and the mechanical stresses in this flexion point. Initial management should include aggressive risk factor modification with antiplatelet therapy (aspirin 81-325 mg daily), high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily), blood pressure control (target <130/80 mmHg), diabetes management if applicable (target HbA1c <7%), and smoking cessation 1. Exercise therapy should be encouraged, with a structured program of 30-45 minutes of walking 3-5 times weekly, continuing to moderate claudication pain. For a 60% stenosis causing significant symptoms (claudication, rest pain, or tissue loss), revascularization should be considered.

Key considerations for revascularization include:

• The location of the stenosis, with common femoral artery disease being preferentially treated with surgical endarterectomy rather than endovascular approaches due to superior long-term patency and the mechanical stresses in this flexion point 1
• The severity of symptoms, with revascularization being considered for significant symptoms such as claudication, rest pain, or tissue loss
• The patient's overall health status and perioperative risk, with surgical procedures being reserved for individuals who have acceptable risk of perioperative adverse events 1

Post-procedure, lifelong antiplatelet therapy and statin treatment are essential to prevent progression of atherosclerosis and maintain patency of the treated segment. The most recent guidelines recommend a combination of revascularization and supervised exercise or pharmacotherapy to improve walking performance and quality of life in patients with claudication 1.

In terms of specific treatment options, the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline recommends revascularization for patients with aortoiliac and/or femoropopliteal disease and claudication, with surgical endarterectomy being a preferred treatment option for common femoral artery disease 1. The ACR Appropriateness Criteria also recommend antiplatelet adjunctive therapy and catheter-directed stent placement as appropriate treatment options for iliac artery occlusive disease 1. However, the most recent and highest quality study recommends surgical endarterectomy as the preferred treatment option for common femoral artery disease 1.

From the Research

Management of 60% Calcification in the Right Common Femoral Artery

• The management of 60% calcification in the right common femoral artery can be approached through various methods, including endovascular therapy and surgical endarterectomy 2, 3, 4.
• Endovascular therapy, which includes techniques such as atherectomy and balloon angioplasty, has been shown to achieve patency rates of 60% to 90% at 1 and 2 years 2.
• Surgical endarterectomy, on the other hand, is considered the gold standard for treatment of symptomatic common femoral artery disease, with primary patency rates of 93% and 91% at 1 and 5 years, respectively 4.
• The choice of treatment depends on various factors, including the severity of the disease, the presence of comorbidities, and the patient's overall health status.
• In cases where the calcification is severe, iliofemoral endarterectomy associated with systematic iliac stent grafting may be considered as an alternative to traditional open surgery 5.
• It is essential to evaluate the patient's specific condition and medical history to determine the most appropriate treatment approach, as evidenced by the various studies 2, 3, 4, 6, 5.

Treatment Options

• Endovascular therapy:
  • Atherectomy and balloon angioplasty
  • Drug-coated balloon therapy
• Surgical endarterectomy:
  • Patch angioplasty
  • Graft replacement and profundaplasty
• Iliofemoral endarterectomy associated with systematic iliac stent grafting
• Combined approaches, such as hybrid procedures involving both endovascular and surgical techniques 2, 4, 5.

Considerations

• Patient selection and evaluation are crucial in determining the most suitable treatment approach 2, 3, 4.
• The presence of comorbidities, such as diabetes and coronary artery disease, should be taken into account when selecting a treatment option 2, 4.
• The technical success and patency rates of the treatment approach should be considered, as well as the potential risks and complications 2, 3, 4, 5.