Continuing the theme of evidence-based medicine and an open dialogue, I wanted to discuss the current state of lower extremity revascularization for patients with claudication and critical limb ischemia. As I am sure this topic will be both controversial as well as informative, I want to focus on the treatment of the superficial femoral artery (SFA) for claudicative diseases.
Currently, revascularization through an endovascular approach has become the default method for therapy in most, if not all, vascular beds. The treatment for peripheral arterial obstructive disease in the lower extremity is no exception. Although the data for this location are less than robust, we all agree with this approach, with few exceptions. What has been shown in the barest sense is that angioplasty is better than medical therapy (MIMIC-Eur, J Vasc Endovasc Surg 2008;36:680-688). Further, several studies have shown stenting to be better than angioplasty alone (ABSOLUTE, N Engl J Med 2007).
Most importantly, this perceived benefit of the endoprosthesis is the durability of the stent we place (i.e., primary patency), but not the clinical benefit from the device compared with a non-stenting or non-covered stent approach (ABSOLUTE 2-year data. Circulation 2008 and VIBRANT, VIVA 2009). This quandary is based on the fact that we as “plumbers” always focus on the patency of the “pipes” in what amounts to a clinical syndrome of claudication. What is the correct answer here? Is it that the vascular surgical groups have it right: Treat only when the claudication is at its worse? Is it the vascular interventionalists who say we should treat more aggressively and early, as this impacts potential heart-healthy lifestyles? Do we have the right approach at all as plumbers? Are the early data from drug-delivery balloons not just a dream but real science? Are the current stent designs not the correct systems for the SFA, whereas novel iterative changes to stent technologies -- woven stents, alternatively designed stents or very conformable stents -- the future for this region of treatment? I don’t know the answers but feel that the current state of stent delivery may not afford the benefit we seek for our patients after an 18- to 24-month treatment window.
Let’s see where this discussion leads and reconvene next month.
Lawrence A. Garcia, MD
Dr. Garcia received his B.A. and M.D. degrees from the University of Arizona. He was an Intern and Resident at Parkland Memorial Hospital, University of Texas at Southwestern in Dallas, Texas. He received his training in Cardiology at the University of Iowa Hospitals and Clinics in Iowa City, Iowa, and as an interventional cardiologist at the Beth Israel Deaconess Medical Center, Harvard Medical School. Further, he received his peripheral vascular training at St. Elizabeth’s Medical Center, Tuft’s University, Boston, Massachusetts. He then served as the Chief of Vascular Medicine and Peripheral Vascular Interventions for the Florida Heart Group in Orlando, Florida. Dr. Garcia returned to Harvard’s Beth Israel Hospital as a full-time interventional cardiologist and Director of the Peripheral Cardiovascular Program and Peripheral Interventions at the Beth Israel Deaconess Medical Center as well as the Director of the Interventional Fellowship Program. This program developed into one of the busiest in the city of Boston, performing over 600 peripheral procedures per year.
Dr. Garcia has now returned to St. Elizabeth’s Medical Center as Chief of the Section of Interventional Cardiology and as Associate Director of the Vascular Medicine Program. Dr. Garcia’s work has largely focused on arterial occlusion-reperfusion models and the efficacy of therapeutic modalities or interventions with regard to free radical generation or endovascular stenting outcomes. Dr. Garcia continues his research interests in a wide variety of studies including acute MI studies, unstable angina studies, interventional trials, peripheral interventional trials, angiogenesis trials, imaging modality studies, and numerous device trials for both the coronary and peripheral circulations. His work has been presented in numerous manuscripts, abstracts, textbooks and textbook chapters.