When is stenting indicated in superficial femoral artery (SFA) angioplasty?

From the Guidelines

Stenting in superficial femoral artery (SFA) angioplasty is indicated for TASC type C and D lesions, which include single stenosis or occlusion longer than 5 cm, and complete common femoral artery or superficial femoral artery occlusions. The decision to stent should be based on the morphological stratification of femoropopliteal lesions, as outlined in the TASC classification system 1.

Key Indications for Stenting

• TASC type C lesions: single stenosis or occlusion longer than 5 cm
• TASC type D lesions: complete common femoral artery or superficial femoral artery occlusions
• Lesions with severe calcification or flow-limiting dissection after balloon angioplasty
• Elastic recoil with residual stenosis greater than 30% following balloon angioplasty

Stent Selection and Placement

• Self-expanding nitinol stents are preferred for the SFA due to their flexibility and resistance to external compression forces
• Adequate lesion preparation with appropriate balloon angioplasty is essential
• Stent sizing should match the reference vessel diameter with 1-2 cm coverage beyond the lesion margins
• Post-stent dilation is typically performed to ensure optimal stent expansion

Post-Stenting Management

• Patients should receive dual antiplatelet therapy with aspirin 81 mg daily indefinitely and clopidogrel 75 mg daily for at least 1-3 months
• The decision to stent should be individualized based on lesion characteristics, anatomical considerations, and patient factors, as stenting provides better patency rates for complex lesions but introduces risks of in-stent restenosis and stent fracture 1.

Important Considerations

• For lesions in the distal SFA near the adductor canal, stenting should be approached cautiously due to increased risk of stent fracture in this high-motion area
• Stenting is not recommended as a routine procedure, but rather as a salvage therapy for suboptimal or failed results from balloon dilation, or as primary therapy for specific lesion types 1.

From the Research

Indications for Stenting in Superficial Femoral Artery Angioplasty

Stenting is indicated in superficial femoral artery (SFA) angioplasty in the following situations:

• Suboptimal technical results after percutaneous transluminal angioplasty (PTA) 2
• In-stent restenosis (ISR) 3
• Occlusions or long lesions of the SFA 4, 5
• TASC A and B lesions, where primary stenting has been shown to provide durable results 5, 6

Factors Affecting Patency Rates

Several factors can affect patency rates after stenting in SFA angioplasty, including:

• Lesion type, with TASC A and B lesions having better patency rates than TASC C and D lesions 5, 6
• Length of the stented segment, with longer segments having lower patency rates 4
• Presence of occlusive restenosis, which can affect patency rates 3
• Use of drug-eluting balloons, which can improve patency rates in cases of ISR 3

Outcomes of Stenting in SFA Angioplasty

The outcomes of stenting in SFA angioplasty can vary depending on the indication and lesion type, but overall, stenting has been shown to:

• Improve patency rates compared to PTA alone 2, 5
• Provide durable results in patients with TASC A and B lesions 5, 6
• Have lower patency rates in patients with TASC C and D lesions 5, 6
• Be associated with a low risk of complications, such as death or major adverse cardiac and cerebrovascular events 3, 2