Cath Lab Digest

Smoking cessation and exercise regimens are the textbook answer to the treatment of patients with claudication symptoms. Surgical bypass can be complicated by wound-healing issues, graft thrombosis, etc. In light of this, the traditional approach to superficial femoral artery (SFA) disease is nonoperative, unless the patient has claudication that is debilitating and prevents the patient from performing their job appropriately.

Percutaneous therapy has changed our opinion of claudication. I (and many others) have become very aggressive about catheter-based approaches to SFA disease. My preference is to treat SFA disease with an angioplasty and stent approach. I utilize atherectomy in only very select circumstances. I have used several different varieties of bare-metal stents with good results. But, stents are not perfect, and I want to use a recent case to highlight some deficiencies.

I treated an 80-year-old man with some mild cardiac disease with an angioplasty and stent for a long-segment SFA occlusion. His ankle index initially improved from 0.57 to 0.81. His symptoms improved significantly. In just 3 months, he presented with recurrent symptoms, and a duplex exam revealed multiple stenoses within the stented segment. I performed a repeat angioplasty with a cutting-balloon technology. Again, the index improved and his symptoms resolved. Again, in a short time, he presented with recurrent symptoms. I performed an angiogram and re-lined the entire stented region with covered stent technology. Again, he did well for a short time. I recently performed an angiogram when he presented with a reduced index and I found the entire stented area to be occluded. I debated between mechanical thrombectomy or lytic treatment, but decided to leave the area alone for now.

I know we all deal with the frustration of treating SFA disease. Thankfully, this gentleman has stable, short-distance claudication and has not developed rest pain or limb-threatening ischemia. I am hoping to not have to perform a surgical bypass.

How do you deal with this?

_______________________________________________________________________________________________________

Ross Milner, MD, FACS

Ross Milner, MD, FACS is associate professor of surgery at Loyola University Chicago Stritch School of Medicine. He was recruited to Loyola from Emory University School of Medicine in Atlanta, where he was associate professor of surgery.

Dr. Milner graduated Cum Laude from the University of Pennsylvania, where he also completed medical school. He was chief resident in surgery at the Hospital of the University of Pennsylvania. He completed fellowships at the University of Pennsylvania and University Medical Center in Utrecht in the Netherlands. Dr. Milner is currently Chief of the Division of Vascular Surgery and Endovascular Therapy at Loyola University Medical Center, Stritch School of Medicine in Chicago, Illinois.