What is the best revascularization strategy for femoral popliteal (femoral popliteal artery) disease?

Best Revascularization Strategy for Femoropopliteal Disease

Endovascular therapy is the preferred first-line revascularization strategy for femoropopliteal disease, with primary nitinol stenting recommended for intermediate-length lesions and an endovascular-first approach justified even for long and complex lesions due to high technical success rates and low procedural risk. 1

Clinical Context and Treatment Selection

The choice between endovascular and surgical revascularization depends critically on whether the patient presents with claudication versus chronic limb-threatening ischemia (CLTI):

For Claudication

• Endovascular procedures are reasonable as first-line therapy for patients with lifestyle-limiting claudication and hemodynamically significant femoropopliteal disease (Class IIa recommendation). 1

• The high technical success rate (>90%) combined with low procedural morbidity makes endovascular therapy the preferred initial choice, even for long and complex femoropopliteal lesions. 1

• Surgical revascularization should be reserved for patients who: (1) fail to respond adequately to endovascular therapy and medical management, (2) have arterial anatomy favorable for durable surgical results, and (3) have acceptable perioperative risk. 1

For CLTI

• Both endovascular and surgical approaches are effective, with the BASIL trial demonstrating equivalent amputation-free survival between the two strategies. 1

• In CLTI, stenting can be applied more liberally for limb salvage and ulcer healing, as short-term patency may be sufficient for wound healing. 1

Endovascular Technique Selection

Primary Nitinol Stenting Strategy

• Primary self-expanding nitinol stenting is recommended as first-line treatment for intermediate-length superficial femoral artery lesions, demonstrating 20-30% lower restenosis rates at 1-2 years compared with angioplasty alone. 1

• The decision to stent is based on clinical indication, lesion length, and complexity. 1

• Modern long nitinol stents (up to 20 cm) with improved fracture resistance have broadened endovascular possibilities for difficult and complex lesions. 1

Atherectomy Considerations

• Atherectomy does not provide significant clinical benefit over balloon angioplasty or stenting and is associated with higher distal embolization rates (2% vs 1.1-1.2%). 2

• When compared to stenting, atherectomy shows higher major amputation rates at one year (5.3% vs 4.1%) and less ABI improvement. 2

• The additional cost of atherectomy is not justified by outcomes data. 2

Drug-Eluting Technologies

• Drug-eluting stents have not demonstrated superiority over bare-metal nitinol stents in the superficial femoral artery. 1

• Early studies with drug-eluting balloons showed improved short-term patency compared with plain balloon angioplasty. 1

Surgical Revascularization When Indicated

Conduit Selection

• When surgical revascularization is performed, bypass to the popliteal artery with autogenous vein is mandatory over prosthetic graft material (Class I recommendation, Level A evidence). 1

• Systematic reviews demonstrate clear and consistent primary patency benefit for autogenous vein versus prosthetic grafts. 1

• Femoral-tibial artery bypasses with prosthetic graft material should never be used for claudication (Class III Harm recommendation). 1

Surgical Advantages

• Surgical procedures may offer superior long-term patency compared to endovascular approaches, but this comes at the cost of higher perioperative morbidity. 1

• Technical factors suggesting surgical advantage include: favorable anatomy for durable results, availability of adequate autogenous vein, and good distal runoff. 1

Management of Endovascular Complications

In-Stent Restenosis

• Balloon angioplasty alone has very high failure rates for in-stent restenosis; repeat stenting should be considered for recurrent stenosis. 3

• No single randomized trial has demonstrated superiority of one technique over another for treating in-stent restenosis. 1

Stent Fracture

• Stent fracture risk factors include: number and length of implanted stents, overlapping stents, calcification amount, and deployment technique. 1

• Modern stents have higher fracture resistance, making this less of a concern with contemporary devices. 1

Critical Caveats

• Do not perform revascularization solely to prevent progression to CLTI (Class III Harm recommendation) - this applies to both endovascular and surgical approaches. 1

• Long-term patency is diminished with greater lesion length, occlusion rather than stenosis, multiple diffuse lesions, poor runoff, diabetes, chronic kidney disease, and smoking. 1

• 20-30% of patients have persistent symptoms despite patent stents, so mild symptoms should not be assumed to resolve spontaneously. 3

• The superficial femoral artery experiences repetitive deformation in multiple directions with leg movements, creating unique mechanical challenges for any intervention. 1