What is the management for a patient with bilateral atherosclerotic plaques in the Common Femoral Artery (CFA), Superficial Femoral Artery (SFA), and popliteal arteries?

Management of Bilateral Atherosclerotic Plaques in CFA, SFA, and Popliteal Arteries

For patients with bilateral atherosclerotic plaques in the common femoral artery (CFA), superficial femoral artery (SFA), and popliteal arteries, optimal medical therapy and supervised exercise for 3 months should be initiated first, followed by revascularization only if symptoms persist and quality of life remains impaired. 1

Initial Assessment and Medical Management

• Evaluate symptom severity, functional limitations, and impact on quality of life to determine appropriate treatment strategy 1
• Implement optimal medical therapy including:
  • Antithrombotic therapy: combination of rivaroxaban (2.5 mg twice daily) and aspirin (100 mg daily) for patients with high ischemic risk and non-high bleeding risk 1
  • Risk factor modification: smoking cessation, blood pressure control, lipid management 1
• Initiate supervised exercise therapy for at least 30 minutes, at least three times weekly for a minimum of 12 weeks 1
• Assess PAD-related quality of life after 3 months of optimal medical therapy and exercise 1

Revascularization Decision-Making

• Revascularization is indicated only if symptoms persist and quality of life remains impaired after 3 months of optimal medical therapy and exercise 1
• Revascularization is NOT recommended for:
  • Asymptomatic PAD 1
  • Solely to prevent progression to chronic limb-threatening ischemia (CLTI) 1

Revascularization Strategy for Femoro-Popliteal Disease

• Drug-eluting treatment should be considered as first-choice strategy for femoro-popliteal lesions 1
• Endovascular therapy should be considered as the primary approach for femoro-popliteal lesions 1
• Open surgical approach should be considered when:
  • Autologous vein (e.g., great saphenous vein) is available 1
  • Patient has low surgical risk 1
  • Complex lesions are present (after multidisciplinary team discussion) 1

Lesion-Specific Considerations

• For TASC A lesions (single stenosis <3 cm in SFA or popliteal artery), endovascular intervention is the preferred treatment 1
• For TASC B lesions (single stenosis 3-10 cm not involving distal popliteal artery, heavily calcified stenoses <3 cm, or multiple lesions <3 cm), endovascular approach is often suitable 1
• For TASC C lesions (single stenosis/occlusion >5 cm or multiple stenoses 3-5 cm), consider either endovascular or surgical options based on patient factors 1
• For TASC D lesions (complete CFA or SFA occlusions, or complete popliteal and proximal trifurcation occlusions), surgical bypass is traditionally preferred 1

Specific Endovascular Considerations

• If endovascular therapy is chosen:
  • Drug-eluting balloons have shown improved long-term patency in complex lesions 1, 2
  • For severe intermittent claudication undergoing femoro-popliteal revascularization, consider treating below-the-knee arteries in the same intervention if there is substantially impaired outflow 1
  • Preserve landing zones for potential future bypass grafts 1

Follow-Up Management

• Regular follow-up at least annually is recommended to assess:
  • Clinical and functional status 1
  • Medication adherence 1
  • Limb symptoms 1
  • Cardiovascular risk factors 1
  • Duplex ultrasound assessment as needed 1

Important Considerations and Pitfalls

• SFA and popliteal lesions have more fibrotic elements with less lipid and degenerative tissue compared to coronary lesions, making them more stable but also more prone to restenosis after intervention 3
• Bilateral disease often indicates more extensive systemic atherosclerosis, requiring aggressive risk factor modification 1
• In multilevel disease, it is essential to eliminate inflow obstructions when treating downstream lesions 1
• Femoro-popliteal interventions face challenges with long-term patency due to the highly mobile nature of these arteries, particularly after stent placement 1